Clinical Decision/Documentation Support

[Gateway]

Hi everyone:

Would appreciate suggestions for clinical documentation support resources - online or print (not too cumbersome) to assist in creating templates for use at work so I can complete my encounter notes more quickly. Our EMR does not have a template feature 

Looking forward to your replies.  Thank you. 

[djmatte, ADN, MSN, RN, NP]

On 12/26/2020 at 12:56 PM, Gateway said:

Hi everyone:

Would appreciate suggestions for clinical documentation support resources - online or print (not too cumbersome) to assist in creating templates for use at work so I can complete my encounter notes more quickly. Our EMR does not have a template feature 

Looking forward to your replies.  Thank you. 

What emr?  Any smart notes options? On mine m, I created smart notes for about 50+ diagnosis over the first year as a NP. Much of this from gathering information from 5 minute clinical and a few other resources. They are standard smart notes that cover the majority of plans and condition direction. They generally cover a disease progression, prescribed meds/therapies, new labs/orders, and any at home remedies such as pt/neti pot/whatever else, and education provided. Basically I created a I went along starting with my most frequent diagnosis. They aren’t perfect, but they reinforce the daily things I tell patients on the regular and at least reinforce my coding.