What EHR documentation tactic, such as a safety-checked SmartPhrase/dotphrase bundle, helps you chart faster without risking copy-forward errors? Creating SmartPhrases is an incredible way to save time. I try to create phrases for educational material and general charting phrases that I use frequently. I make sure to make the material generic and then if I need to add anything specific to one individual I will add that on later. I also make the name of SmartPhrase easily identifiable and unique to avoid accidentally selecting the wrong one. Can you give one example of a note section you templated that saved time and improved clarity? For a normal physical exam I create a template of my version of a normal exam. That way I just select the SmartPhrase rather than clicking through everything or hand typing the same thing.
I use a dotphrase bundle when documenting the review of systems to prevent copy-forward errors. The dotphrase for my review of systems has all the relevant signs and symptoms. I go over each one with the patient and document actively in the note as I speak to them. For the assessment and plan section, I typically review each diagnosis by reading actively with the patient, making sure all up-to-date information is entered. Aleksey Aronov AGPCNP-BC Adult Geriatric Primary Care Nurse Practitioner - Board Certified VIPs IV https://vipsiv.com New York, NY