The dust has finally settled from initial EHR “go-live” implementations. Providers and staff now have the chance to work with the application, which leads to the inevitable request to customize Allscripts v11 Note Noteforms and templates. Let’s face it; the delivered content does not fully fit everyone’s needs. Depending on how the initial implementation was conducted regarding note build, even the specialty specific content may leave users needing more customization.
Unfortunately, practices often fail to develop an ongoing process to refine and optimize their notes to better suit their evolving documentation. This often leads to frustration, complaints and a feeling that users have to cater to the system’s needs. However, customization, albeit often tricky can provide many benefits to your organization and your end users. Beware that while too much customization means you end up doing a lot of work, too little customization means you end up changing the way you document to fit the EHR.
Advantages to Allscripts v11 Note Form Customization
Successful customization depends on a few key factors: strong leadership, full involvement of physician advisory groups and clinical staff in the design and content to be included in the note, as well as strict adherence to timelines and budget. Below are a few advantages to customization:
- Maximum efficiency
- Reduction of clicks
- Streamlined workflows and limited errors
- Minimal user frustration
The end reward is saving money and improving the quality of your record keeping. Better documentation also reduces liability.
The Downside to Allscripts V11 Note Form Customization
Here are a few reasons why some organizations may decide not to customize their notes:
- It can take a long time
- An increased overage of man hours
- Increased Cost
Too much note customization with each provider having their own version of the same visit note can lead to the need for increased support when troubleshooting issues.
Proceed with caution
Helpful tips to keep in mind if you decide to customize; remember note forms and templates are a tool for organizing, presenting and capturing clinical data. Here is what we recommend:
- Customize note forms to match your workflow.
- Follow SOAP Note format – subjective, objective, assessment, and plan.
- Select default output for specific fields and use keywords or phrases on the input view.
- Select the correct layout to eliminate the need to scroll to critical fields for information.
- Eliminate certain pop-ups such as confirmation screens.
- Order pick-lists to allow the most commonly selected items to appear at the top.
- Schedule regular staff communications and mandatory staff trainings.
- Providers and coders must be involved in any note form customization.
Customizing note forms or templates will not only make them easier to use but also help ensure that documentation is accurate. In turn it will also increase the accuracy of quality reports. When multiple fields or terms are used to collect the same information reports may not correctly produce all of the terms used in your charts.
Other customization tools that can be utilized:
Text templates contain any number of blank fields, which are marked by empty brackets [ ] or multiple-choice options indicated with a text choice between square brackets. For example, [ text ]. The selected text block inserts text directly into the output file thus streamlining physician documentation. Practices/organizations also utilize third-party tools to enter notes according to their desired workflow.
Examples of these tools are:
- Speech & transcription (i.e. DRAGON) – a speech recognition software used to gather information using voice dictation or free text.
- Patient populated documentation forms – These forms (bubble sheets or tablet) are given to the patient at their first visit to the practice. The patient completes the form. The information/data is captured and then written to the correct fields in the chart.
- Deploying a remote scribe to accompany the provider and take dictation to complete the documentation.
Thoughtfully designed note forms will present immediate benefits in efficiency and ease of use for the practice. So even though a practice will likely invest some up-front time and/or additional money getting their note forms up to speed, the investment is likely to pay off down the road. (In the long run)