EHR templates can help busy providers save time while ensuring clinical documentation is consistent, high-quality, and complete.
But how can you make the most of your templates?
EHR templates tips and best practices
Below are ten best practices for optimizing EHR templates (sometimes called macros or dot phrases, depending on your EHR vendor) to ensure your clinical documentation is as efficient and accurate as possible. If you’re relatively new to templates, these best practices will help you begin with a solid foundation.
Tips for Getting Started
1. Review and update templates regularly
Templates are most valuable when thoughtfully customized based on your typical visit types and documentation preferences—schedule time to review and update your templates regularly, at least twice a year.
You’re off to a good start if you’re reading this article. Incorporate these tips and remove outdated templates you no longer use.
2. Customize practice-wide templates
Sometimes a template provided by your administrator needs tweaking. Instead of editing the template each time you use it, make the edits once and save the updated template for future encounters.
3. Choose memorable titles
Each template is associated with a name, the phrase you will use to quickly find the template and add it to the notes section of your EHR. Some interfaces also have a shortcut or dot phrase associated with each template.
Make template names and shortcuts memorable and easy to say, and avoid using numbers in the titles.
4. Chunk down your templates
Creating long templates with many note sections for a typical visit type can be tempting. However, having too much text in a single template adds more editing time and contributes to chart bloat.
The solution is to extract common elements from existing templates or past encounters.
For example, in an operative (op) report, the preamble of each report contains the same information (name, DOB, patient man, anesthesiologist, type of anesthesia, etc.). Use one template for the preamble and a second for the actual procedure (e.g., ankle replacement or Achilles tendon repair).
If you have long templates, use a process like this to chunk them into more specific units.
Now that you’ve mastered the basics, here are some more advanced tips for using EHR templates effectively.
5. Incorporate dynamic fields
Avoid having multiple similar templates by incorporating dynamic fields you customize for each visit.
Dynamic fields are drop-downs or text boxes that you edit to specify common variables like sidedness or an assistant’s name. Some software can link these to the patient chart to automatically populate known variables (like DOB).
6. Add placeholder sections for personalization
You can also leave larger blank text sections within the template with prompts to add unique details.
This is a great way to balance consistency with accuracy by making it easy to personalize your notes to the specific visit at hand.
7. Share templates with your teammates
Consider the hours you save each month using carefully customized templates to streamline clinical documentation. Why not share this with your teammates?
A new resident could benefit enormously from seeing how you have set up your EHR templates or from using them as a draft to customize their own.
Advanced tips for EHR templates
For those with a streamlined templates workflow, the next step is fully integrating your templates with every documentation system you use.
8. Combine templates with medical dictation
Templates naturally fit with physicians’ other favorite time-saving documentation technology: speech recognition.
Leading medical dictation apps like Mobius Conveyor allow you to use a voice command to insert a template. Then you can navigate the blank fields or down menus by stating “next field.”
Pairing speech recognition with templates can drastically speed up your documentation efficiency, but it also encourages nuance. When you don’t have to waste time typing, including a powerful narrative capturing essential details about your patient and their healthcare is easier.
9. Use your templates across EHRs
Major EHR vendors all have a templates function built into their clinical documentation software. But what if you change hospitals or move between different EHRs throughout your work week?
Third-party apps like Conveyor offer an interoperability solution for providers who want to bring their templates as they move between EHRs.
Conveyor’s dictation interface has built-in text macros so you can say two words to type a whole paragraph. Place your computer cursor where you want to dictate, speak into Conveyor on your iPhone, and use any of your saved templates anywhere you can type.
10. Make your templates mobile
There will be times when you want to dictate clinical notes away from your laptop or desktop computer. Fortunately, mobile medical dictation apps with integrated text macros make it easy to use EHR templates from anywhere – in the car, at home, or even at the point of care.