Physician Medical Record Templates

The Emergency Department documentation templates offered by represent an attempt to get back to basics and simplify the entire process. Directing the record to the critical elements required for full reimbursement of all visits, while allowing individualized documentation for proactive risk management and good communication with other providers. The system is very simple to learn with only 3 primary templates suggested. One for adults, one for pediatrics and one for trauma. A few second-line templates are available for rechecks, fast-track "quickies" and additional procedures. For teaching hospitals, there is a full set of amended templates for residents in teaching institutions that provide for Attending physician supervisory notes that comply with CMS regulations and are consistent the needs of risk management and good care in the teaching environment, yet allow very rapid completion.

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Our template philosphy is simple and reflects the Moto at "TAKE CARE OF BUSINESS AS WELL AS TAKE CARE OF THE PATIENT". The templates are simple and very limited in number allowing for rapid familiarization. This means that providers can very quickly gain the benefits of increased productivity offered by templated systems. They incorporate a system that allows grading of complaints and findings rather than the simple "POS" or "NEG" responses used by other systems. Effort has been made to assure plenty of space for free entry of data so each chart is in fact individualized and continuity of care issues can be explicitly documented. Simplicity means low cost, ease of customization and no storage space issues. All templated records allow documentation of level 5 exams. This means that "unexpectedly" complex visits still allow quick compliance with documentation of all required elements needed for high complexity visits using the templated areas.

The design of any system should take full advantage of the system's strengths and also fully address its inherent shortcomings. Proper documentation by Emergency physicians is a critical chore that must be done correctly. A well done record provides the basis for :

  1. Good patient care by ensuring communication with other providers.
  2. Legal documentation to assure that physicians are fully reimbursed for their services.
  3. Documentation to protect the physician from medical malpractice risk.
  4. All quality assurance audits.

Bottom Line:

If your group is handwriting charts, it is time to change. you are losing productivity, money, and friends (medical staff), increasing your malpractice risk, audit exposure and risking the wrath of JCAHO for illegibility.

If you are dictating, consider youself lucky to be funded and supported. but consider use of templates with dictated addendums to substantially increase productivity. Even Macros cannot match time saving of templates completed at the bedside.

If your group uses other templates such as T-System, you should consider the advantages of our system. I have been providiing physician education on documentation and overseeing audits of T-System charts for over 7 years. Our templates address the regularly expressed and documented shortcomings of their system.