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Default Encounter Template

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The working diagnosis is Acute Bronchitis. ... I'm adding Hx Recurrent URI's, Smoking, and Hx acute bronchitis for this patient example. ... – PowerPoint PPT presentation

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Title: Default Encounter Template

1
Default Encounter Template

Anthony Inae, M.D.
anthony_inae_at_chcsii.com

2
What is it?

Everyone should have a Default Encounter Template
set-up as a default, and ideally, prior to seeing
patients on CHCS II. This is a template that
will Automatically load an Encounter Template
that consists of a Generic S/O Template (a.k.a.
Visit Template or Medcin Template), List of
Common Diagnoses, Commonly used Orders
(especially labs), Common Procedures (CPT codes),
and Other Therapies (Patient Education
documentation). When set as default, it will
load for every patient, every time.
Each Specialty should have their own, as a
starter, that users can use initially then when
providers become more proficient, each provider
should know how to tweak to better match what
they do, this includes
Editing that default S/O template via S/O module
Adding / removing other A/P items via Template
Management
Adding Orders via Save to que and Save as
Order Set
Removing Orders via Template Management
The purpose of this template is to speed
documentation when you do Not have a disease
specific S/O Template or Encounter Template.
The following slides will show what a default
encounter template consists of.

Notice here in Template Management under My
Favorites, there is a template that has the
words (DEFAULT TEMPLATE).

I have named mine, AAA load first for all
visits. (Side Note If you search the live
system for AAA, you will see my S/O template.
Also, search AMI, and will find my disease
specific templates).
Whenever I go into a new encounter, this is my
HPI tab.

Here is my PMH Tab, with all the common social
and history items.

This is my ROS Tab. In it has common Symptoms
that my patients typically complain of.

This is my PE Tab. In it has the Alert/Oriented
stuff and commonly examined areas.
2. I put these in my default template to minimize
having to search for these physical exam findings
all the time.

This is my Tests Tab. In it I put my EKG
interpretation, when needed.

This is the Diagnosis Tab in A/P. Notice my
default template is still loaded.
In the Diagnosis Tab, I pre-populate all my
common diagnosis.
You may be taught to use the Add to Favorite
List button, and click Favorite List button to
get to your favorites, but by putting things in
your Default Template will save you 1 extra
click and every click saved, is increased
efficiency.

This is only an example of what my Order Sets tab
would look like. On the live system, I have all
my commonly used labs, a few X-Rays, and just a
couple of meds.
This tab is most useful for placing all your
common labs, in particular. Ordering Rads and
Meds through the respective tabs are easy enough,
and minimizes the clutter on this tab. i.e. less
scrolling, searching, etc, saves time.

Here is my Procedure Tab. In it, I have all the
CPT Codes I could possibly do for any visit.

The last tab that can be put in an Encounter
Template is Other Therapies.
You can see here, that this covers several
diagnoses, i.e. Diabetes, HTN, Hyperlipidemia,
peds stuff, etc,
More from my list is below.
This is my Prevention stuff, as well. Remember
PPIP (Put Prevention Into Practice). I used to
get dinged for not having that Second P in my
notes. Here it is.

13
How to use the Default Encounter Template.

Anthony Inae, M.D.

14
Default Encounter Template Use Strategy

This template is best used when you do not yet
have a disease specific template made (or
borrowed) saved to your My Favorites list.
I have found, when you have a disease specific
template or AIM form, documenting is easy, demos
look slick...
in reality, everyone who has actually used CHCS
II in seeing real live patients realizes that
when you dont have a template, this is where
people slow down but not me.
Heres my strategy (first will write out the
steps, followed by step-by-step screen shots)

15
Default Encounter Template Use Strategy Cont.

1) Assumption I know that I dont have a
disease specific template for the patients
problem.
2) I interview / examine the patient and have a
working diagnosis in mind.
3) I go to A/P, pick or search the diagnosis,
submit orders, other therapies, etc off my
default template (as much as possible), and order
meds, etc when needed. Basically, finish the A/P
first. (You may choose to do otherwise. I find
it best to knock out the A/P first, so if I have
to move on to the next patient before writing my
note, the patient can leave, and I will remember
why the patient was here).
4) I start my S/O documentation process.

16
Default Encounter Template Use Strategy Cont.

5) Important Exhaust full use of your Default
Encounter Template, by clicking on whatever you
can in each of the tabs. (Youll see why later,
but doing this minimizes bouncing back and forth
between templates, etc).
6) So, in the HPI tab, I usually click on Visit
For and free text the history purposely trying
to omit any symptoms (as symptoms are best
entered via medcin for a multitude of reasons).
7) Then click on the PMH tab, click anything
pertinent with free text, if needed.
8) Then click on ROS, if you see a symptom from
your default template that is positive, then
select it , add free text if needed, then
click the HPI/ROS button to flip it up to the
HPI section (this will start you off with 1
medcin term in HPI to help with coding).
Continue flipping up any other positive symptoms
from your ROS list, if there are any. Then click
on any negative ROS symptoms in your default list
without flipping (this will give you more ROS
items, that basically drives your EM code).

17
Default Encounter Template Use Strategy Cont.

9) Click on the PE tab, and check off those
basic things you did on this patient, especially
the Alert/Oriented stuff and other parts of the
exam you might have done, i.e. looked into the
ears, felt the neck, heart, lung exam. (These
things may or may not pertain specifically to the
disease process the patient is here for. You
will do this next).
10) Now, click the Dx Prompt button and search
for a diagnosis. The system will automatically
bring back related symptom, PMH, PE exam findings
related to that specific disease. Expand List
Size to 3, if more related terms are needed.
(Note if you have no clue as to the diagnosis,
then do a Prompt on the patients main symptom.
I will explain how later).
11) March through the HPI, PMH, PE tabs once
again, adding those disease specific items to
your note. (The reason for checking off the
Default Encounter Template items first, is
because you see, the Dx Prompt does not bring
back those other items that you already checked,
nor does it bring back the Alert/Oriented stuff.
By doing it first, means you dont have to go
back now to do it, i.e. saves time).

18
Default Encounter Template Use Strategy Cont.

12) Free text anything remaining of which, you
dont have a medcin term in front of you. It is
not worth frustrations fighting the system, and
really not worth the time to keep searching or
pecking the tree. Because, by this time, you
should have enough medcin terms in your note to
give you an appropriate EM code, as opposed to
doing everything in Free Text (I know we are not
coders, and the system is not trying to turn you
into coders but if done this way, you maximize
the probability that the system will generate a
more correct code appreciate the fact that you
dont work in a civilian practice).
13) You are done with documenting the S/O and
already finished A/P, so now go directly to
Disposition, and Sign.

Assumption I do not have a disease specific
template for this diagnosis/visit. I must
document by creating a note on-the-fly so to
speak.
Here are the screen shot steps. The working
diagnosis is Acute Bronchitis. Also, please
dont judge the medicine, but try to pick up the
concepts.
I start with the A/P on the Dx Tab. Double click
on Acute Bronchitis to add to the patients
note. It is in my Default Template.
My default encounter Template can handle just
about any diagnosis that I see, as you will see.
I do not have many encounter templates. I do
have quite a few disease specific medcin
templates, though.

On the Order Sets Tab, check off items that you
want to order. Again, put all your common things
here, to minimize having to always search for
them. Saves time. (Note My real default
template on the live system has more labs. Here
Im using the training database and am limited.
Please just understand the concept here)
I checked an Abx, CXR (also checked Modify, and
CBC.
Then click Submit at the bottom.

Since the modify button was checked for the
CXR, need to put in a reason, then click OK

Now must remember to click Submit to continue
submitting the order.

Orders are submitted.

Now click on the procedures tab, and add any
procedures, by double clicking on the item. For
this example, I will add PFT (This is just an
example of adding a CPT, not clinically relevant
for this patient scenario).

Now click on Other Therapies tab, and add any
items here from the default template. In this
case, I will remind the patient to quit smoking.

Now on to the S/O module.
Concept here is to Exhaust the use of the Default
Template (though out each of the tabs) before
leaving it.
You have to think differently about documenting.
This is the fastest way I found and to be most
efficient, without jumping back and forth between
modules/templates/ searches, etc.
On the HPI tab, I usually check Visit for and
free text stuff, trying hard not to type symptoms.

On the PMH tab, Clicked on tobacco use, and
added free text 3 pks per day. Dont forget to
hit Enter (else your free text will be lost
forever promptly increasing your frustration
level).
Next clicked - on family history of Asthma,
then clicked the History button, to get rid of
the words family history, to make it mean
personal history.

On the ROS tab, Clicked on cough, and added
for 3 weeks. This can be done with free text,
or I used the Duration button.

Notice that Cough for 3 weeks is under Review
of systems section in the note. I want to put it
in the HPI section. To do this, click on
ROS/HPI flip button at the top (next slide).
29

Notice that Cough is now in the HPI section.
Now I will add wheezing, and will flip it up to
the HPI section, also (next slide).

Notice Wheezing is now in the HPI section of the
note.

Still on ROS Tab Now click - on any remaining
negative items. Notice it goes to the ROS
section (my default template was created with
this in mind, all symptoms in the ROS tab). This
is good for a couple of reasons.
One, is that it makes for a more readable note,
i.e. only positive findings in the HPI section
Two, having symptoms in the ROS section basically
drives the EM calculator. i.e you will
consistently have a lower EM code if you have
nothing in the ROS section. It is just how the
software calculates the code.

Now on the PE tab Click on anything useable
from this Default Template. This may or may not
pertain to the reason why the patient is here.
Notice this is the time to document things like
vital signs reviewed, or the patient was alert,
etc. I commonly look in ears, can document the
heart and lung exam here as well.
This is what I mean by Exhausting usage of this
template. This means I will not have to go back
to it during this encounter documentation process.

Now click on the Dx Prompt button at the top.

Type Acute Bronchitis, and click OK

Select Acute Bronchitis and click OK

Now click to the HPI tab again. Notice that
Symptoms related to Acute Bronchitis come up.
This is not a template, but inherent in the
system. Symptoms, PMH, and physical findings are
mapped, and weighted by relative frequency to
diagnoses (next slide).

Clicking on the List Size button twice brings
the List Size to 3. This gives you more related
symptom terms, as shown below.

Now click on any other or - symptoms here.
Basically adding the disease specific symptoms.

Now, on the PMH tab, click anything pertinent.
Im adding Hx Recurrent URIs, Smoking, and Hx
acute bronchitis for this patient example.

Skip the ROS tab, and go to the PE tab.
Add in any other physical findings or -.
These are again, the disease specific PE
findings, pulled from the Dx Prompt.
Now jump to Disposition, because the A/P is
already done.