Take my Word for it

May 5, 2006

The author's simple charting system is light years away from an EHR. But it just might be the thing to save your practice time and money.2005 Writing Contest-Best Practice Solution 2005 DOCTORS' WRITING CONTEST-BEST PRACTICE SOLUTION

It's been a year since my transcriptionist and I parted company-and I have no regrets.

Without too much trouble, I've been able to take care of all my charting and correspondence in about three-quarters of the time I used to. And I've accomplished this feat without purchasing an expensive software system or electronic health record. Instead, I use my office PC and Microsoft Word, which has many advantages over the traditional dictation/transcription alternative, not the least of which is cost.

Transcription rates tend to run between 10 and 14 cents a line. Over the course of a year, the total transcription bill can add up to a significant portion of a small practice's operating budget. Add to this the time it took me to dictate and review the transcribed notes-up to an hour and a half, depending on how busy I was-and the whole operation was costly in both time and money. By contrast, the time it takes me to do my own typing is a negligible cost. It helps, of course, that I was the second-fastest typist in Miss Houston's ninth-grade typing class.

AutoText makes documentation easy

One of the Word features that has proven most helpful to me is the "AutoText" function. Using it, I can enter extended portions of text with only a few keystrokes. This has allowed me to set up templates for routine office encounters, which can be pulled up and modified depending on the findings at each visit. This works because any given chart note follows a predictable pattern. For example, if my review of systems and my physical exam for a given patient are normal, I can document this fact quite easily, without having to dictate a component-by-component summary.

I didn't develop my templates all at once. In fact, every time I typed a note and found that I'd be likely to use it again, I hit "AutoText" and added it to my template menu.

The entries I've set up follow the SOAP format, CPEs, and more complicated medication reviews. Within these frameworks, I can easily fill in a few lines of pertinent history.

When it comes to the objective portion of the exam, I can document very thoroughly in only a fraction of the time. In fact, documenting a completely normal exam takes only a few keystrokes. For instance, when I type "ente" (the first keystrokes of "ent exam"), a full, normal ENT exam pops up. At this point, I can either edit the AutoText entry-by changing "TMs normal," say, to "R TM red and bulging"-or I can leave it as is, and go on to the neck, respiratory, and other parts of the exam that I've just performed.

I've also established AutoText entries for each organ system individually, as well as entries for grouped-together systems. Finally, I've established in Autotext a complete, head-to-toe physical. It's easy to pull up, and is dramatically quicker than if I were to dictate the normal exam.