Optimizing Medical Note Templates

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1 Optimizing Medical Note Templates

2 Presented By: Optimizing Medical Note Templates Christa Weghorn Performance Improvement Specialist IDEXX Laboratories Robert Tope, DVM

3 Agenda Benefits of Medical Note Templates Medical Note Templates: What to Consider Formatting Medical Note Templates Documenting ed Information Putting Medical Note Templates in Practice

4 Benefits of Medical Note Templates

5 Medical Note Templates What are the benefits? Consistency Legibility Accessibility Search ability Backed up in case of disaster if proper backup procedures followed

6 Medical Note Templates: What to Consider

7 Medical Note Templates What to consider? Begin with the end in mind Internal use: exam findings External use: report card Determine templates per visit type Preventative care (Wellness) Sick Surgery

8 Medical Note Templates What to consider? Begin with sample templates Sample-Dental Exam/Cleaning Sample- Eye Exam Sample- Canine Neuter Sample- Feline Neuter *Top 10 Reasons for Visit

9 Formatting Medical Note Templates

10 Medical Note Templates Creating a Standard Format Decide on a beginning template Save starter template Create template for each visit type based on starter template using: Bookmarks Text input fields Check boxes Pictures

11 Practice Introduction Electric City Animal Hospital Dr. Robert Tope, Owner Anderson, SC Practice type: small animal, exotics 14 staff: 10 full-time; 3 doctors Cornerstone user since 2002 Chartless practice Cornerstone version: 8.1 Integration IDEXX VetLab Station and suite of analyzers IDEXX DR1417 Digital Imaging System 15 Cornerstone workstations

12 Putting Medical Note Templates into Practice

13 Medical Note Templates Putting it into practice Routine cases Anesthesia monitoring, spay, neuter and dental Atypical cases Sick

14 Medical Note Templates Anesthesia Monitoring Modify existing templates to get started or create your own Be creative including what you want and need (AAHA) Input charges in the invoice item pane (PVL)

15 Medical Note Templates ECAC Example Examine pet prior to anesthesia Fill in anesthesia monitoring template Technician or doctor can enter charges via PVL (groups are great!) Monitoring while in OR Attach monitor data to medical note

16 Anesthesia Monitoring

17 Medical Note Templates ECAC Example Surgery notes/discharge instructions can be done intra-op or post-op Combined, to save a step Additional notes can be added Picture of pet added to help with bonding and creating value

18 Canine Spay

19 Medical Note Templates Dental Example The sample dental template is great! Can be modified, as others ECAC added content, picture Ideas: Add dental pictures, radiographs Great charting record for future dental procedures

20 Dental Exam/Treatments

21 Dental Exam/Treatments

22 Medical Note Templates Physical Exam Note Template Create physical exam template for sick visits Format with questions that technician would ask, physical exam findings, etc.

23 Documenting Other Patient Information

24 Documenting Information Where to Store ed Information Link ed files in Medical Note Attachments tab Medical history from another practice Emergency reports Referral letters Faxed prescription requests Insurance forms

25 Attachments Tab

26 Questions? Please complete survey and turn in Next sessions: Driving Consistent and Profitable Medicine Using Defaults and Smart Groups Best Practices in Inventory Management Instructor-Led Lab: Enhanced Medical Note Setup for Paper Chart Practices

27 Thank you for attending Optimizing Medical Note Templates

28 Cornerstone is a trademark or registered trademark of IDEXX Laboratories, Inc. or its affiliates in the United States and/or other Countries. All other product and company names and logos are the trademarks of their respective holders.

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