Custom iPad EHR Notes

[How to Make Your Own EHR Custom Note Template

From Dr. John Giacalone]1

In my humble opinion, one of the most powerful features of drchrono is that you can produce an extremely quick and efficient note without taking away from the doctor-patient encounter and without losing your unique personality in each and every note. Many of us have spent many years developing a specific style that we favor while writing our SOAP notes — a style that we are comfortable with; one that meets medical necessity expectations.

Instead of detailing every single option for making a custom template, I will focus on the {{value}} variable and discuss the most important aspects that will be sufficient for 95% of everyone using drchrono.  Additionally, what I am about to cover will empower the other 5% to explore the omitted options and master them through trial and error.

Before you begin to make your own custom templates, drchrono has many wonderful preset features and I suggest that you use them first.  Get to know each and every preset note template.  What this will do is provide you with a glimpse of the power of drchrono and it will also give you a few ideas on how you can fine-tune drchrono to sound exactly like you.

The first step in customizing your notes is to reverse engineer what you consider to be your finest patient note.  Working from the whole to form the individual parts will allow for a smoother overall experience.  Trial and error is inevitable but with repetition and fine-tuning, your custom note will evolve into a work of art.  To help illustrate the process, I have taken the liberty of creating a very general patient note using the Medicare-based PARTS format.  I will also make that note available to each of you so that you can have the basic framework to play with.  If you do nothing else but start with this template, you will have a complete note that shows medical necessity in the eyes of Medicare.

Now that you have your finest patient note, the next step will be to identify two different portions of the note: the concrete portion and the variable portion.  The concrete portion consists of the parts of the note that never change.  No matter who the patient is and the circumstances of their visit, these key parts will remain the same.  The variable portion is unique but predictable.  For example, not every patient will have the same region of the complaint, but every patient has the same exact regions.  So, while the complaint will be unique, you can still predict the possible regions.

Once you have finished identifying what is concrete and what is variable, you are ready to log in to drchrono.  Go to “Clinical Tools” and choose “Custom Workflow Editor.”  Welcome to your custom note laboratory.  Having this screen in front of you will be necessary for the final paragraphs.

Fortunately for you and me, you do not need any experience with programming to program your own custom note template.  You are intentionally limited to a few very well constructed pre-made variables in the top left corner and truthfully I typically use only one, {{value}}.  The “allowed values” box is where you will always list the variable portions that you found in your finest patient note.  Where you place the {{value}} variable in the SOAP sections will dictate where the “allowed values” appear in your generated SOAP note.  For 95% of doctors, the “SOAP note line item type” will always be set to “Field”.  “Field” allows you to place the variables of your finest patient note into the blank “Allowed values” box.  If you would like to select multiple variables at once, simply choose the option “allow for one or multiple values”.  You may find this valuable for sections like pain quality where the patient lists multiple descriptors instead of just one.

Now for a valuable tangent.  I want to emphasize the following point: it is completely acceptable to enter absolutely nothing into the “allowed values”.  What this will do is allow you to type whatever you want when you reach this box in your custom template note from your iPad.  This is very powerful because sometimes it will take more time for you to go through a list of 100 items neatly typed into the “allowed values” box than it will for you to simply type the name of the two items in question.  For example, it will be easier for you to simply fill in the blank for the appropriate subluxation complex than it is for you to type every possible variable into the “allowed values” box and then scroll through the options to select the appropriate subluxation complex.  This principle will carry through for many circumstances where you find yourself wasting time searching for the appropriate option.

Now choose a name for your custom template, set aside a little time and let the creative juices fly.  Employ the tips I have shared with you and even use the template I created to help illustrate the reverse engineering process from my original patient note.

Click here to copy Dr. John Giacalone’s template into your own drchrono EMR/EHR account.

Don’t have an account yet? Easily create a free drchrono EMR/EHR account by clicking here.