Physicians have designed and used a variety of medical record templates that save time, as well as significantly improve their charting.
Q. Electronic health records are too expensive for my small family practice. Can you recommend any low-tech and low-cost systems or shortcuts that would help make charting more accurate or less onerous, while still providing malpractice protection?
Fortunately, medical record templates needn't create an unreasonable burden of either time or money. They prompt doctors to consistently document detailed information pertinent to each patient encounter.
Most of you are probably familiar with "SOAP" or "SOAPIE" templates from medical school or residency. If you're one of the doctors who's gotten out of the habit of using these very useful templates when making your progress notes, here's a refresher course: "S" stands for the patient's subjective complaints, "O" is for the doctor's observations or findings, "A" means the doctor's assessment or diagnosis, and "P" represents his plan for treating the patient's condition. In the expanded version, "I" denotes the doctor's intervention, and "E" means his evaluation of the patient's response to treatment.
Emergency physicians, orthopedists, and other specialists often use complaint-specific templates to facilitate documentation of their exams, diagnoses, and treatments. The templates contain prompts that serve as useful reminders to record relevant information they might otherwise omit, such as normal and abnormal findings from exams, lab tests, or radiology reports.
One caveat, however: All spaces on the templates must be filled in or voided. A blank space does not indicate whether a specific exam was done or omitted, and would not be accepted in court as evidence of a negative finding.
In addition to templates, some word-processing programs (like WordPerfect and Microsoft Office) allow you to create "macros" that can be valuable time-savers for physicians who dictate their medical records. With a single keystroke or two, each macro can produce a large amount of information that you assign to it. Let's say you create a macro for the observation "normal chest" and assign it to the "Alt-X" keys. When you dictate "normal chest," the transcriber hits the Alt-X keys, which call up your detailed description of the elements that constitute a negative chest exam. That stored text is then inserted into the record. "Pause codes" inserted into macros prompt the user to enter patient-specific data or exam results.
Your specialty society or your malpractice insurer's risk management department may have downloadable templates that are suited to your own practice.
The author is a risk management and loss prevention consultant in Cloverdale, CA. He can be reached by e-mail at firstname.lastname@example.org
This department answers common professional liability questions. It isn't intended to provide specific legal advice. If you have a question, please submit it to Malpractice Consult, Medical Economics, 5 Paragon Drive, Montvale, NJ 07645-1742. You may also fax your question to 973-847-5390 or e-mail it to email@example.com