Note templates will allow staff to easily and efficiently chart their findings and activities when meeting with and operating on patients.
In this article, you will learn:
- When to use chart vs. operative note templates
- How to create a new note template
- How to use the formatting tools
- Tips and Tricks
- EHR Template Library
- Dictation
> View Video Below<
When to Use Chart vs. Operative Note Templates
There are two types of note templates:
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Chart notes are used for any non-procedural appointments such as consultations, pre-procedures, and follow ups
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Operative notes are used only for procedures
Chart notes enable recording of the visit type, SOAP (Subjective/Objective/Assessment/Plan) documentation, and diagnosis. They are provided for all non-procedural appointments.
Operative notes enable recording of assisting staff members, inventory usage, and diagnosis. They are provided for all procedure appointments.
How to Create a New Note Template
To create a new note template from the Main Menu, navigate to Practice Account -> EHR Templates, then select EMR Chart-Note Templates or EMR Op-Note Templates depending on whether you want to create a chart or operative note template respectively.
To get started, complete the top input fields as indicated. If one or more Treatment(s) are selected, these treatment(s) will be ADDED as the Visit Reasons to the appointment - this was developed as a shortcut workflow for providing treatments on the fly during the encounter, so it is strongly encouraged to leave this field blank. If a Treatment is selected, then the option to identify a default Diagnosis is also provided.
Choose to create either a simple chart note template or utilize the SOAP inputs as:
- Subjective: describe the patient’s current condition in narrative form
- Objective: document objective, repeatable, and traceable facts about the patient's status (vitals, lab results, etc.)
- Assessment: describe the medical diagnosis
- Plan: describe what will you do to treat the patient (ordering labs, procedure performed, etc.)
Operative notes provide the same Treatment input field as chart note templates and also allow the indication of supporting staff members during the procedure.
To add template content, click into the white input field and type your standard content for the template you are creating. Typically a template is created for each treatment where the charting information would be unique. See below for how to use the formatting tools.
All note templates include Patient Visit Summary for content to be shared with the patient after their visit.
How to Use the Formatting Tools
When adding content to the input fields, there are many formatting tools in the toolbar allowing you to customize the layout of your content.
The Short Text provides input for a short, single line of content. By double clicking on the text box, you can customize the width and add helper text to guide the user.
The Long Text provides input for a detailed answer with several lines of content.
Note: To get 1 spacing between the lines of the text- click Shift+Enter. To get double spacing - click Enter.
Double click on the text box to add default text.
Use the Checkbox to enable the user to select multiple options. Input the different selection options and decide whether to display the options vertically or horizontally. You can also choose to have the unchecked choices not display when the note is rendered as a PDF to make the note summary easier to read.
Use Radio buttons to enable the user to select only a single option. You can also select a default option to display.
Use the Dropdown Menu to enable the user to select a single answer from a list of options in a pulldown menu. You have the ability to display any empty options in your list as well.
The rest of the options function similar to standard word formatting tools.
Once all formatted has been completed and the template has been assigned a name, click the Save button and your new template will be added to the list of templates on the right.
Tips and Tricks
When creating a new template, it can be faster to copy the formatting from an existing template and edit the components as needed for your new template.
1. Highlight the section of the existing template which you'd like to copy and use your keyboard copy function to copy the content to your clipboard.
2. Select the Clear button then paste the copied contents into the empty input field.
3. Edit the contents to reflect your new template, provide a template name, and save the new template.
Note: to draw attention to a section of content within a block of text which needs to be edited while charting, highlight the content as red text (see above) or yellow background (see below).
Additional Resource: How to Use Charting Tools
Another trick on how to create a new template quickly is by using the content from existing templates. If you have templates in your library that are similar to the template that you want to create, you can just copy-paste the content and adjust it to the needs of your new template. This will help you save a lot of time on building templates.
Template Library
Our EHR template library is an accumulation of EHR chart and op note templates created by our community of practices. Please see the following articles in order to jump start your EHR template content:
Dictation
Some practices are successfully using Dragon speech technology to enable dictation for charting the patient encounter within Remedly. If Dragon software is installed on the computer, it can be used to dictate notes by clicking in the Procedure or Chart Note field within the EHR template to get started. There is no special integration required.
Video
Content Timelines per Minute:
00:00 - 00:07 - Introduction
00:08 - 00:23 - Difference between Chart&Operative Notes
00:24 - 00:42 - Remedly Note Templates
00:43 - 3:38 - Creating a Chart note template
3:39 - 3:49 - Looking for a template in the templates list
3:50 - 4:12 - Editing a Chart note
4:13 -4:20 - Deleting the template
4:21 - 4:45 - Adding templates to your practice from Remedly template library
4:46 - 7:24 - Creating a new template based in existing templates