Love working with patients, hate having to manually enter data to create medical progress notes? You’re not alone.
Unfortunately, there’s no getting around creating these standard medical records. Medical progress notes are extremely important for monitoring the efficacy of treatments and communicating patient information. They are also essential for the filing of health insurance reimbursement claims.
While you can’t do away with medical progress notes completely, you can complete them more quickly. In this post, we share three tips for doing that.
Write medical progress notes faster
Here is what you can do to write clinical patient notes more quickly.
And that’s a good thing. Templates save you time and eliminate the need for creating records from scratch.
Electronic health record (EHR) software programs usually offer template options. However, if you do not have EHR software, you can download templates online. Alternatively, you can design your own template based on your unique needs.
Use a ready-made template or design your own; just don’t waste time creating medical progress notes from scratch.
Use checkboxes and dropdown lists
When creating your own medical progress note template, or adapting an existing one, be sure to add checkboxes, dropdown menus, and similar features whenever possible.
Having lists of items to select, as opposed to just fill-in-the-blanks form fields, saves you time since it reduces the amount of searching and typing that you need to do.
Lists and menus also have the advantage of preventing spelling errors and freeing you from having to rely on memory to add specific, hard-to-remember information.
Save standard terms, phrases, and descriptors
Repetitive language is standard in medical progress notes.
Instead of typing these standard terms, phrases, and descriptors from scratch each time, type them only once and save them somewhere accessible. That way, next time you need to use them, you can retrieve them and add them to your notes (for example, by copying and pasting).
The idea is to create a library of standard phrasing and vocabulary—including intervention words, patient presentation descriptions, themes of sessions, treatment approaches, diagnostic codes, and more—so you can add them to your clinical patient notes without having to fully type them.
If you do not have software that provides this already, you can create your own lists of frequently-used terms and phrases. Some of these lists are available online—this list of commonly used intervention words for mental health progress notes is an example.
“Progress notes planner”-style books such as this one also provide a comprehensive catalog of health-related terms and descriptions for different types of practices.
Having a repository of essential phrases to draw from when creating medical notes isn’t just a time-saving measure—it’s also a way to ensure you use the right spelling as well as the correct tone and language every time.
TextExpander for medical progress notes
To get even more out of the tips above, use TextExpander. TextExpander is a shorthand typing tool that lets you summon up words, phrases, and templates with just a couple of keystrokes.
Using TextExpander, you can create templates for medical progress notes and make them appear on any page or platform with minimum typing.
TextExpander has several customization features, which means you can create truly customizable templates. For example, you can add form fields, checkboxes, and dropdown lists to make them even easier to fill out.
TextExpander is also a wonderful tool for storing repetitive codes, terms, and phrases. You can create a library of standard medical terms, phrases, and descriptors on TextExpander to add them to documents without having to fully type them.
You can also share them with your team to ensure that everyone uses the correct terminology and appropriate language when recording patient care and treatment.
Dr. Jeremy Sharp, aka The Testing Psychologist, uses TextExpander to insert diagnostic codes, write results sections, populate recommendations, and sign reports in seconds. He created a series of helpful videos to illustrate how he does this—we encourage you to check them out!
Try TextExpander free for 30 days
TextExpander saves medical practitioners, therapists, veterinarians, dentists, and other health care professionals hours each month by eliminating the need to fully type repetitive words, codes, and phrases.
Incorporating TextExpander into your workflow will not only help you create medical progress notes faster, but will save you time that you can use to focus on work that really matters to you.