Using Templates Effectively (Dictation)

The templates contained on this site are set up for use with the popular Dragon dictation software, though they can also be used as smart phrases in popular medical records software.

Most of the criticism against using templates in medical documentation revolves around the increased tendency to 'copy and paste' incorrect information.  To avoid this problem (or at least minimize it), the templates on this site are designed for customization.  Anywhere you see text in [square brackets] is designed so you can jump to these sections and change the information in that section.  You can jump to these square bracket sections by simply using the fast forward „„ and rewind ƒƒ buttons on your dictation microphone.


In most of the templates there are suggested options that suit different patient presentations.  You can also customize these templates by adding your own [square bracket] options.

If you are using the Epic medical records software, you can change the [square brackets] to triple asterix (***), and jump around the text by pressing the F2 button.

If you are using different dictation software, please feel free to share in the comments how you are using the templates in the comments below.

Welcome to ED Smart Chart

Hello,

    If you're anything like me, you have spent a significant amount of time completing charts on patient encounters in the emergency department.  You have missed countless dinners with family, movie start times, children's soccer games, and meet ups with friends to name a few.

   To be clear, you didn't miss these important life events providing patient care.  You were likely sitting alone in your resident space, office or out on the floor, just trying to complete the mountain of charts from your shift.  Whether you dictate or type your notes, it is difficult to keep on top of all of the necessary charting during a busy shift.

    The goal of this site is to share templates that I have used to cover common medical complaints seen in the ED.  I have used these to help improve my charting efficiency, and now I'm sharing them with you, free of charge.  They are designed so that you can modify them to the individual patient, so that it is not just a cut and paste.  You can learn more on how to use them with common dictation software programs here.  Many of the templates include links to useful resources including decision rules.

    These are by no means perfect, but my hope is that it is easier to improve a set of templates as a community than it is for someone to start from scratch.  So where you disagree with these templates, I welcome you to take to the comments, so we can improve them together.

    As I am writing this, we are in the midst of the COVID-19 pandemic that is affecting so many, but has also shown us how great our community is at rallying together in times of need.  I am inspired by my colleagues who have shared educational material and other resources for free during this time of need, and hope this contribution helps in some small way.

Sincerely,

Ken McManus DO