Laura Cote, Au.D Audiology Supervisor VA Southern Nevada Healthcare System
Boilerplate : A report writing format that provides a basic outline of the report completed by deleting portions of typed text, or adding in portions of typed text Boilerplates are the first step of template creation process Benefits: fast and familiar Disadvantages: Very high risk of inaccurate or inaccurate or contradictory information
CASE HISTORY: [X]Patient completed the case history form and reports the following information: [X]Patient did not complete the case history form but verbally reports the following information: [x] Hearing loss: Bilateral Unilateral right ear / left ear [x] Noise exposure: Pre military: not reported During military: not reported Post military: not reported [x] Patient reports NO family history of hearing loss [x] Tinnitus: NONE Bilateral Unilateral right ear / left ear [x] Dizziness described as: NONE light headedness imbalance vertigo [x] Ear problems/diseases: NONE otalgia pressure and fullness bilaterally [x] Other reported health problems: See problem list
Template: A point and click report writing format that requires minimal free text and is stored in the templates section of the CPRS
Template field: An instruction inserted into the template that directs to a specifically formatted list of 2 or more choice items Examples are: choice buttons, combo boxes, free field text boxes etc.
Finished report has correct grammar and spelling Eliminates the use of abbreviations Minimizes documentation error Proper creation and use of templates will ensure compliance with documentation and JCAHO reviews
Fast report writing Reduces repetitive motion injuries Standardized report format makes it easier for others to find information Speeds peer and/or chart review
Easy tool for new staff or students to use as they begin to learn CPRS if templates are stored in the shared templates section by your clinical applications staff Serves as technical training tool for new technicians, students, or staff by modeling the essential elements of care that should be part of a patient appointment
Please review the supplemental attachments on how to create or work with templates If you find yourself adding the same information in more than 3 separate progress notes within a 2 week period, you should add that information to your template as a choice You can edit your personal templates but only a clinical applications coordinator can edit shared templates
Time is required to develop and update Evolving process – updates will be needed over time May require assistance from clinical informatics personnel to create, update, or import Patient specific detail could be lacking if enough choices and detail are not provided for selection through the template design Generic statements or word choices may need to replace the specific, for example automatic could be used instead of vendor specific universal or autopro
Documentation committee and/or ITS approval needed to import shared templates in many facilities Must be imported not downloaded When importing templates from another facility, not all template fields will be recognized and may need to be recreated locally (contact the templates author for assistance)
Design included asking the VA Audiology community to share their templates and reports. The large number of boilerplates received were consolidated by function and condensed, using the informational choices that were commonly already in use in most VA clinics. These were edited, used in our clinic, revised and sent released for beta testing. Beta testing revealed many barriers to sharing and helped fine tune the templates which were then shared nationally. These have since been update to reflect the last contract changes. My thanks to all of you who participated in this process.
Impression Hearing Aid Order Evaluation Hearing Aid Orientation Class Hearing Aid Dispensing Hearing Aid Return for Credit Hearing Aid Repair /Adjustment ABR ABR Latency Intensity function
Shelly Walsh Clinical Application Coordinator (Shelly.Walsh@va.gov) Laura Cote Au.D Audiology Supervisor Laura.Cote@va.gov
WORDS ARE POWERFUL They create strong images, revealing the message the author wishes to convey and in doing so reflect the author
I think the tinnitus may be a result of his continuing to hunt than the left ear is the obvious choice, since he has a history of acoustic trauma and he shots right handed. Type II deadbeats mellitus consumes 3 bears per night He does report urinating a couple of times a night on his prostate pill. Never married. Widowed since 1996 when wife died from diabetes. 5 children. 9 grandchildren. Lives with a couple.
Example of actual advertisement
Recommend
More recommend
