As we all transition to a centralized electronic medical records for hospital charts, it's critical for us to create, productive workflows, and to maximize utility of these electronic medical records. One great way to do this is using auto text templates to streamline your dictations. This is one of the most beneficial features of Cerner PowerChart, and other EMR's.
Here's how you create useful and effective auto text templates on Cerner Powerchart to stremline your workflow.
How to create templates for your patient encounters
Input preset patient details
Include baseline values
Use dropdowns
Create multiple partial templates
Create jump-to's
Putting the templates together (Examples)
Tip #1 - How to Create Templates
Creating templates on power chart is simple with these steps:
Log onto Cerner Powerchart
Once you've logged on, go to your toolbar on the top and click on auto text copy. This will bring you to the auto text copy page.
Click on the manage auto text copy icon and this is where you will be able to create, delete and manage your templates.
To create a new template, click on the blue plus icon.
Create an abbreviation and description for your template. The abbreviation is how you will access the template from your note, so keep it standardized and keep it simple. For example, I like to start with ".." and keep everything organized. For example, all my operative notes start with "..or[insert OR name here], ie "..orShoulderReplacement".
The description can be the longer for the full description of what this template is.
Then start creating your template. If you've access to a dictation program, I suggest you use this as it will be much quicker than typing.
Tip #2 - How to Insert Patient Details
Cerner PowerChart has the ability to personalize the notes within your templates. To do this, you can access the available tokens with this icon with the paper and the plus sign in front of it. For example, you can access it to place tokens, such as referring doctor, patient first name, date of birth, age and almost any clinical aspect, including allergies, home, medication's, etc. It's quite powerful and really goes along way to helping populate a comprehensive note.
Tip #3 - Have Baseline Default Values
If you're like me with an elective practice as quotes of specialized, you're probably asking the same questions over again with common answers. For example, I do upper limb, and so I always ask handedness and most people in the world or right hand dominant. In this case, it makes sense to have a default value of right hand dominant under this question so that it's populated automatically for a majority of the patient population. This again goes to save you a significant amount of time.
Tip #4 - Use Drop Down Lists
Well, default values are great, not every one is the same. Behind Miss examples excellent for this, and while most people are right hand, dominant, mini or not a mini or ambidextrous. This is great for a drop down menu. To create a drop-down menu, click on the drop-down menu icon, and it gives you the ability to write out all of the options that you want included. It will also give you the ability to create a default value which combines the previous tip and this one.
Tip #5 - Create Multiple Partial Templates
Many times you will not be able to use a full template for all of your patients either because of the variety of pathology's and presentations you see, or because of limitations within the software. A great example of this is in the operative notes, you are forced into various sections, that all need to be inputted. Therefore the best way to do this is to create multiple short templates that you can bring up into each of the different sections. As an example with the operative notes, our templates are pre-filled to have a clinical note, an operative note, and a post operative plan, all of which are Different fields. Therefore, I have a template that I can call out for each of these sections. Similarly for consult notes, if I am discussing with patients things like post operative rehabilitation, it will differ whether it's a shoulder, elbow, ham, wrist, or something in the lower limb and therefore I have a post operative rehabilitation spiel that I can call up for each one of these.
Tip #6 - Create Jump-To's
Creating jump-to's is also a very important efficiency tactic. If you are mostly typing, you can make use of underscores. Anywhere that has an underscore (_), this can be jumped to, by pressing the F3 button. This prevents excessive mouse clicks. Similarly, if you have access to, a dictation software such as Mmodal, you can create square bracket jump to's ([ ]) and these can be accessed by pressing the next button on your microphone. Again, this makes the actual dictation experience itself much smoother and prevents excessive mouse clicking.
Tip #7 - Share Your Templates
The great thing about these templates are that they are shareable. Whether you sharing with your colleagues or the trainees that are coming to your clinic for a short time, this is a great opportunity to make sure that you are notes are standardized, and that your entire team continues to be efficient.
Final Output
Many people have the argument that transcription is faster. I have tried both ways, and I have to say well. There is a little bit of upfront work in creating the templates, overall, my flow and efficiency has increased much more with the use of these templates. As an example, I can literally dictate entire OR notes with three clicks! If you found this helpful, please consider subscribing to the newsletter. If you have any productivity tips in terms of using templates, I would love to hear them in the comments below!