We've heard that before. And it's so true. Good medical documentation is essential because it reflects your clinical thought process. Your notes are crucial for the continuation of care, to ensure you are compliant with billing, and to protect you in case of a lawsuit. Your notes are the expression of your digital identity as a physician.
When I started using templates many years ago, the most obvious benefit I saw was that I got more efficient at charting. But quickly, I realized there was another impactful gain: by using customized templates and dot phrases, charting enables me to improve my skills as a physician and provide better care to my patients.
Most medical errors are... human errors! By incorporating templates into your practice, you are sure nothing slips through the cracks. With a patient with chronic diarrhea, there are many elements you need to assess. You ask the patient for any recent antibiotics or travel, suspected food poisoning, or untreated water drinking. You ensure that no other household member has similar symptoms, and may ask if the patient is a man who has sex with men. With the quick pace of today's medicine, if you don't use a "diarrhea" template, there's a risk of overlooking essential elements. This could lead you to misdiagnose.
Here are other examples of how templates assist you:
- As: Never forget to ask for LMP in a female patient with abdominal pain, preventing you from missing an ectopic pregnancy.
- As a : In a patient complaining of hip pain, rely on the template to suggest examining the lumbar spine in case the pain is a referred one.
- As a : Have this hint in your pharyngitis template: "If SGA test is negative, consider checking for STI risk factors (gonorrhea)."
- As a : Include all red flags in your headache or low back pain templates
Using templates appropriately ensures your note and your patient's assessment are not missing important details.
Templates become very handy when you store knowledge in them. Enrich your templates with anything you may need to access during a patient visit. New guidelines, indications, and contraindications of a new medication and links to online pages or videos are good examples. Therefore, templates act as a second brain for everything you learn that you're concerned about forgetting.
Over time, you constantly improve your templates. When you learn something new, update your templates on the go so that the information doesn't need to be stored elsewhere. That knowledge becomes instantly accessible when it is most valuable: during the patient encounter.
Some physicians even push their use of templates to the next level: they move all their notes, medical knowledge, and references to their templates. Everything new they learn from CME, they store in templates. That knowledge becomes instantly accessible when it is most valuable: during the patient encounter.
Some may say that using templates could lead our memory to become lazy ("no need to remember this anymore, it's all saved in templates"). But the fact is our memory and knowledge are not fully reliable. In reality, templates have the opposite effect on our memory:
Templates don't exist to be a substitute for your thought process. View them as an add-on to improve your differential and solidify your medical decision-making. You learn from the templates you have created and updated yourself, while you keep full control over documentation.
Using templates shouldn't be optional. all physicians should integrate into their workflow to ensure the quality of care. When templates are customized your way, they progressively improve your skills, by acting as a security net, giving you point-of-care reminders, and serving as your knowledge base. You continually assimilate their content, therefore improving the quality of care you provide.