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808H Progress Note Templates 101

Reasons for using note templates. Templates prompt for necessary information to reduce errors of omissionHelp speed up note entryProduce notes with a predefined layout for easier readingTemplates help reduce spelling errorsTemplates reduce the use of unapproved abbreviationsImprove documentatio

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808H Progress Note Templates 101

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    1. 808H Progress Note Templates 101 Dr. Charles Demosthenes CBOC Smyrna (Atlanta VAMC) Dr. Michael Cho CBOC Knoxville (Mtn. Home VAMC) Jenny Pangle CIO Memphis VAMC

    2. Reasons for using note templates Templates prompt for necessary information to reduce errors of omission Help speed up note entry Produce notes with a predefined layout for easier reading Templates help reduce spelling errors Templates reduce the use of unapproved abbreviations Improve documentation for billing and JCAHO requirements Patient info can be inserted automatically into the note

    3. Class Objectives Create a new folder in personal templates Create a personal template Insert template fields and data objects into your template Demonstrate & Use tools to manage templates

    4. Templates Considerably improved over the old "Boiler Plated" templates Contains predefined text, template fields and data objects Simple to build and easy to use Allows for multiple selection of items

    5. Other Template Types: Group Templates, Dialogs and Folders Group Templates Allow multiple templates to be placed under one heading Pulls all templates within the group into the progress note Dialogs Also contain predefined text, template fields and data objects More selection options than with templates Folders Used to organize dialogs & templates

    6. Template Field Types Blank text or word processing fields Drop down boxes with predefined text Check boxes that allow for multiple selections Radio buttons that allow for only one selection Calendar boxes Number boxes Hyperlink boxes Template fields can be set to be "Required" { } brackets are used to identify "Template Fields" within the template

    7. Data Objects Imports patient data into the note Examples include recent meds, vitals, age, patient name, etc. Brackets | | are used to identify “Data Objects" within the template example: |patient name|

    8. Template Editor Display

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