I'm a surgeon and we like speed and simplicity. AC has a lot of what I need.

I wish:

1) I would like a separate section for Past Surgical History. Separating that from the PMHx is often critical for us.

2) A check box to turn on/off each section when it may not be needed. I only need all of the boxes on the initial consult or encounter

3) Ability to set preferences to start each new note with a clear page. I don't need all of the PMHx/All/Meds/Social for a post-op note or even a simple f/u note. I find it very cumbersome to see a post-op patient, pull up the patient to write the note and every field is filled with the entire H&P. I need a quick SOAP note format for follow-ups. That way someone can come in after a lap chole, I can click one template which is almost always the same thing, sign it and be done.

I would think FPs would need that for f/u of a kid after a URI or a UTI in an adult. Just a quick 4 line note and out the door.

4) A one click template to fill in several sections at once (i.e. standard H&P would fill in the standard ROS, standard social hx, standard Physical Exam) which would then be easy to change the one or two areas that are out of whack.

Sorry, but I am not understanding why seeing all pertinent information like PMH on each encounter is cumbersome for you. I find it to be extremely valuable. For instance, it might be critical to see in a glance that a patient has had a TAH but not a BSO. However, if you really do not want that information to show up, when you open a new encounter, simply click on "file", "new note", "blank note". This will clear all the other fields. One may also select in the letter-writer, which sections are to be included in the letter. If you are sending out a consultant's letter, you can select which sections of the encounter you want included in your note. If you do not want PMH or SH to show in your letter, deselect these.
Personally, as a referring physician, I appreciate seeing the PMH, FH, SH, MEDS history that other physicians have obtained and often find they have information I did not aquire from the patient.

Leslie

Thanks for the tip. I understand if you like to have all the history in front of you every single time. I'm a newbie so I was unaware of being able to clear all the fields. I do wish it was an option that I could just one-click for a new blank note.

When I say cumbersome, I mean when I send my referring docs a note. I usually just send them a copy of my note. I've already sent them a copy of my full consult so I usually just send them a 4 line post-op note in f/u saying that the patient is doing fine. It's a bit cumbersome to send the entire history everytime especially if the patient has a weekly or bi-weekly wound. I understand I can do some more "clicking" and eliminate it. I'm just trying to find ways to eliminate clicking (which is why I'm going with AC and not e-MDs or eclinical works).

That is the bonus of those pieces of software. If I open a patient in the post-op period, I click "post-op lap chole" and it fills in a standard note and off it goes. I'm just trying to take the good parts of that software and bring it into AC in a simple way.

So I think if you could have templates for entire notes, that would be great.

Don't get me wrong. I have reviewed far too many EMRs and AC fits me better than any of the others.

I see your point. I know of know way to create templates for entire notes but I agree, it might be nice to have.

Leslie

JTU, just like every other damn thing in the world of microsoft you have to find out the 'features' the same way you play a game of Mario Brothers, stumbling around until you 'discover' something new. So forgive me if you already have this down, but when you open the patient chart, type "Control - N" and you will get a new note, the CC, HPI, ROS, PE, A/P all being cleared. For most of us, having the PMedHX, FAM, Soc, ALLERGIES, and Meds stay populated is an advantage.
I agree with the Need to set Surgeries in one spot, my work around is type, "SURGERIES" first thing in the PMedHx box and then after listing or updating the list of surgeries, I have the Medical Hx listed. (I rarely type the word "MEDICAL HX" because HTN or DM type II are self explanatory and I am lazy.)
As for a check list, the best I could offer would be a template that says, "SURGERIES: The patient has had: (type the whole damn list). and then, "The patient denies: (cut and paste the whole damn list)
To use the template I would right click to bring up the templates in the Past Medical History box and click this template, then delete all that do not apply, and at the end of the first list, append any unusual surgery that the patient had which is not on the list. Then drop to the second paragraph and delete the surgeries from 'denied' that the patient did have. Cumbersome, but I think it would go pretty fast.

Jon is aware that this would be nice. Apparently it is difficult to create a whole note template. It would make my life simpler.

Personally, I would like to be able to use a previous template for the physical only. If I do an annual exam on a patient, there likely will be little to change the following time I see them, say, to follow up their BP. Their murmur should still be there, their DJD changes persist, etc. I would like to just right click and be able to choose a previous exam and then make any adjustments in the note. While the exam may not change, the plans rarely are the same so the current option of using a previous note are not helpful to me. SoapWare had this feature and it is one thing I miss.

Leslie

You could also use the addendum function and instead of bringing up a full note just make an addendum with a template for followup visits. They still show up in the previous notes section and you could just print and mail them to other providers.

When you save the note, you get the option to just save a SOAP note which is a lot shorter and gets rid of several sections of the full note. The note that is saved doesn't include all the boxes. You can use a template in the Assessment or Plan section for your usual boiler plate - or a template in the letter writer. In the letter writer, you get the option to pick and choose which sections (boxes) of the note to include in your letter.

JTU, everytime your MA's put a postop patient into a room, train them to open the chart and press "CTRL-N" enter vitals or CC: or whatever they routinely enter and forward to your inbox.

That way you have fresh page to write on every time and it saves you the step of "CTRL-N".

However I do a lot of medical followups, and when it comes to a patient having multiple medical issues (DM, HTN, hyperlipidemia) it's nice to have all that information from the prior office note already their to serve as a template for my followup. So I do not have the staff use the CTRL-N feature.

I will use CTRL-N if the reason for the new visit is appreciably different from the prior visit.