Electronic health record templates are customizable forms that help providers collect, present, and organize clinical data. When used appropriately, templates can reduce typing and help physicians spend less time on documentation and more time with patients.
Optimize your EHR
The medical record plays many roles. It is the home of patient data and the primary communication tool between different health care providers. It’s also the basis for reimbursement claims and a legal document that must withstand scrutiny.
For all of these reasons, good EHR documentation is paramount. But how can providers complete a thorough note without getting bogged down by the growing load of charting and paperwork?
The role of EHR templates
Templates are one answer. Many providers find themselves typing large pieces of text that reoccur based on typical visit types. Templates are customizable forms that providers can easily apply to different sections of the EHR.
Well-designed templates are short, easy to use, and include pertinent positives and negatives. Once added to the note, the template becomes a seamless part of the chart text.
As one EHR vendor puts it, “The residue of the template in the chart should be a complete note to mark the clinical encounter that meets documentation standards with minimal extra typing and no unnecessary chart bloat.”
Most certified EHRs include a library of standard templates by specialty and the ability to customize templates or add new ones. To get the most out of the EHR, most providers will tailor their templates based on standard visit types.
The primary benefit of templates is efficiency. Providers with optimized EHR templates can streamline their documentation workflow and get back hours of lost time. In addition to these time-saving benefits, templates can act as a reminder to ensure complete care while helping standardize data capture.