# Presentation: 463184

## 160HProgress Note Templates 101

- Philip Bloechl, IT Specialist
- Dr. Michael Cho
- Tennessee Valley Health Care System

## 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

## 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

## 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

## 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

## 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

## 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|

## Template Editor Display

- SUBJECTIVE
- |PATIENT NAME| is a |PATIENT AGE| year old |PATIENT ETHNICITY| |PATIENT SEX| presents with chief complaint of {FLD:VEHU EDIT BOX 20X60}
- ALLERGIES |ALLERGIES/ADR|
- MEDICATIONS |ALL ACTIVE MEDS COMBINED|
- OBJECTIVE
- VITALS
- Blood Pressure: |BLOOD PRESSURE|
- Temperature: |TEMPERATURE| Pulse: |PULSE| Respiration:|RESPIRATION|
- PAST MEDICAL HISTORY: {FLD:VEHU WORD PROCESSING}
- TOBACCO USE: {FLD:VEHU YES/NO} {FLD:VEHU TOBACCO USE} {FLD:VEHU NUMBER 1-2}
- ASSESSMENT: {FLD:VEHU WORD PROCESSING}
- PLAN/RECOMMENDATION: {FLD:VEHU WORD PROCESSING}
- RETURN TO CLINIC: {FLD:VEHU NUMBER 1-12}
- SCHEDULE PROCEDURE ON: {FLD:VEHU DATE/TIME}

## Example: Template display in CPRS note

## Lets Go!   SIGN ON TO CPRS

**Find your student number ## by your computer****Click this Icon:  **** **
**Access Code: ****##VEHU****	**
**Verify Code: ****VEHU##**
**Your patient is****<****your number spelled out****>,****patient**
**Your Signature Code is ****VEHU##**

## Select your Patient

- Find the patient that corresponds to your number, ( I will be using zero, patient)
- A Patient Record Flag (PRF) will be presented
- Select "CLOSE" to exit the PRF
- Signature Code is VEHU**##**
- Progress Note templates are created in the NOTES tab.
- Click the CPRS NOTES Tab.

## Slide 12

## Questions?