Electronic Health Records may be 'the wave of the future'
but what about 'the wave of the present'? If you're a
busy practitioner hard pressed to keep up with the volume
of patient records, you need help now. Transcription services
are expensive and many in general practice especially,
prefer to keep their own records. The difficulty, as ever,
is time. Typing out everything yourself is onerous yet
writing out records by hand can be messy at best and unreadable
at worst. Poor record keeping continues to plague the
profession. For a look into the depth of the problem —
and the plethora of proposed solutions — take a moment
and type "poor physician record keeping" into Google.
You'll find that it continues to be a problem on a massive
scale. The following may not be the ultimate solution
but it may help whoever does your record keeping save
about 25% of their time and increase the accuracy of their
work considerably. The secret? Two underused features
of Microsoft Word: AutoText and AutoComplete.
TEMPLATES
MADE EASY
AutoText allows you to insert whole sections of text
that you have previously entered with a few keystrokes.
These include charts and tables. Anything that you can
produce in Word can be flagged in AutoText and quickly
called into a document. You can, for example, create
a template for a 'normal' physical exam and then call
it up and modify it to reflect a given patient's condition.
Anything that you repeat in your practice can be added
to AutoText from form letters to patient and colleagues
and referrals to routinely prescribed drugs and everything
in between.
This is how to use it:
- Open a new document in MS Word
- Set up a document that you
use frequently, for example, a Subjective Objective
Assessment Plan (SOAP) form. Include only those headings
that repeat from form to form. You can make the chart
as simple or complicated as you like. If you haven't
used the "Tables" function in Word often, you might
want to try it. It's simple and highly useful in organizing
material.
- Highlight the material you want
to be able to recall with AutoText.
- Click "Insert" in the dropdown
menu at the top, then "AutoText."
- A window will pop up where you
can fill out the name of this new AutoText —
pick something you'll remember.
- Click "add" in the same window
— and now you'll have the AutoText in place,
easily accessible from the AutoText toolbar.
To insert it into a document:
- Click "Insert" in the drop down
menu.
- Click "AutoText."
- Type in the name you've given
the particular piece of text you wish to insert.
- The "INSERT" box will automatically
highlight. Click it and the selected text will appear
at the cursor in your document.
Don't burden yourself with trying
to enter everything at once. Produce your templates
gradually as you prepare them when seeing patients.
Add anything that's likely to be repeated to your AutoText
file and before long you'll find that as much as 25%
of the repetitive typing tasks have been eliminated.
Your charts will also look a lot cleaner if you've used
tables.
LET
WORD DO IT
AutoComplete is another feature that has the power to
cut the time spent on patient records. It's what automatically
changes common typos like "teh" to "the" on the fly.
That's all fine and good but AutoComplete's real power
comes when you customize to expand your shorthand. For
instance, if you find yourself frequently typing "type
II diabetes" you can use a non-word of your choosing
— like "di2"— to automatically expand to the
full disease name.
Here's how you do it:
- Find the pulldown menu in MS
Word called "Tools."
- Select "AutoCorrect." A window
will pop up — make sure the box "Replace text
as you type" is checked in this window.
- Also in this window enter
all your timesaving shorthand. Put your shorthand
in the box that's labelled "Replace" and put the full
terminology in the box called "With."
That's all there is to it. Now
each time you type the shorthand version, the program
will automatically enter the full and complete version.
SHORTHAND
SAMPLES
The possibilities are limitless, but here are some ideas
to get you started:
- Use "mytitl" as shorthand for
your name and title.
- Use shorthand for colleagues'
names you frequently type. For instance you could
put "drf" for "Dr Featherstone-Haugh"
- Use "inst" as shorthand for
the name and address of your place of work.
- Come up with a shorthand term
for towns or cities or provinces you need to type
frequently. Typing "sask" instead of "Saskatchewan"
might save you a lot of time in the long run.
- Use shorthand terms for diagnoses
like "iddm" to expand to "insulin dependent diabetes
mellitus."
The great thing about adding AutoComplete
and AutoText entries is that it requires so little time
to set up and you don't have to dive in headfirst. Just
add a few entries as you think of them. As you become
more savvy you can start adding things like partially
completed forms for typical patient cases — like
birth control refills. Once you get to this level you're
practically using your word processor as an EHR.
Doctors who have tried the system
swear by it. Like many of the overlooked things in this
high tech world, it's an 'intermediate' technology and
it's those that often work best. If you don't want to
begin to type your own records using the system, the
least you can do is teach it to the person who does.
One other tip: If you do use it, take the time to develop
the initial templates, it's highly satisfying to watch
them reproduce automatically.
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PATIENTS & PRACTICE
