Laura Cote, Au.D Audiology Supervisor VA Southern Nevada - - PowerPoint PPT Presentation

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

• r 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

• f 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

• f 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.

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