How to Master Medical Documentation Using Dot Phrases in 3 Easy Steps
Looking for a straightforward way to expedite your medical documentation without having to spend a fortune on a scribe or dictation software? Using dot phrases (also known as smartphrases or autotext) is the way to go. The “trick” is to really master the art of writing notes with templated text.
This approach can help you finish all your clinic and hospital notes on time without having to stay after hours to complete your progress notes or H&P’s. Many clinicians struggle with medical documentation. When they have finished with clinic or their hospital shift, they still must spend an hour or two finishing their notes.
For tips on establishing your workflow during your day at the clinic, check out this and this article, which cover such topics as RTPC (Real-Time Pre-Charting) and setting up favorite orders in your EHR. The discussion below outlines a strategy to help get you started with dot phrase documentation.
Many healthcare professionals already know the benefits of using templated documentation or at least know of a colleague who is a “super user” and is a dot phrase guru. This guide will show you a way to get started toward achieving the same elite status.
- Identify your top 10 conditions.
- Create your dot phrases for these conditions.
- Continue to grow your list of templates until you have a comprehensive library of dot phrases.
Step #1. Come up with your top 10 conditions.
It’s easy to get started with dot phrases. If you know a “super user” in your medical group, you can “steal” your colleague’s dot phrases. Some EHRs, like Epic, allow clinicians to share their smartphrases. Others, like Cerner, are a bit more restrictive and require users to obtain approval from a committee to share autotexts with others.
But simply copying or gaining access to a group of dot phrases won’t solve your medical documentation headaches. Since you are probably not familiar with the content, you most likely won’t know how to use them effectively.
The solution? Start small. First, identify the 10 most common conditions or patient visit scenarios you deal with at work. For example, if you work at urgent care, your top three might be UTIs, colds/URI and acute gastroenteritis. If you work as an outpatient primary care clinician, they might be diabetes, hypertension and hyperlipidemia. Or, if you work in the hospital, they might be chest pain, pneumonia and sepsis.
Regardless of your line of work, the key is to createa short list of the most common diagnoses or conditions you treat and create dot phrases you will need to complete those visit notes.
Step #2. Create your dot phrases for these conditions.
Once you have developed your top 10 list, then you can get to work. This might take a few hours, but it is time well-spent. You will have plenty of return on your investment.
Again, you can borrow your colleague’s dot phrases to save some time. Or, you can tap into resources like StatNote to get access to more than a thousand dot phrases and templates for the most common conditions in primary care, urgent care and inpatient medicine.
Whether you create the dot phrases on your own or borrow them, the key is to tailor them to your specific needs and become very familiar with their content. Avoiddot phrases that are bloated with information; you want to keep them short and simple, and quickly get to the point. Nobody wants to read a novel when reviewing a note. Try to use bullet points that are easy to read.
Remember that the three goals of medical documentation are billing, legal protection and conveying your thoughts and findings of the encounter to other healthcare professionals. Medical documentation should focus on helping you meet these three objectives and supporting your clinical reasoning. Efforts to document anything extra is probably a waste of your time and will just end up bloating your note with unnecessary information.
At StatNote we follow the KISS principle: keep it simple, stupid–or to be more politically correct, keep it short and simple. Following this principle will enable you to capture the essentials of your patient’s visit and, most importantly, quickly edit and tailor your template to accurately document what transpired. Inaccurate documentation can affect patient care and your recollection of events.
Take a look at this sample SOAP note.
HPI Hypertension On lisinopril. Compliant with medications. Does not report any headaches, blurry vision, dizziness, chest pain, shortness of breath, or palpitations. Following a low salt diet. Exercising. PE General: No acute distress. Awake and conversant. Eyes: Normal conjunctiva, anicteric. Round symmetric pupils. ENT: Hearing grossly intact. No nasal discharge. Neck: Neck is supple. No masses or thyromegaly. Respiratory: Respirations are non-labored. No wheezing. Skin: Warm. No rashes or ulcers. Psych: Alert and oriented. Cooperative, Appropriate mood and affect, Normal judgment. CV: No lower extremity edema. MSK: Normal ambulation. No clubbing or cyanosis. Neuro: Sensation and CN II-XII grossly normal. A/P # HTN Controlled. Continue current medications. No change in management. Discussed DASH diet and dietary sodium restrictions. Continue/Increase dietary efforts and physical activity.
Using bullet points in your documentation makes the editing process easier. It can also help as a guide that prompts you to ask or review key elements during the patient’s encounter.
In addition, these templates can help you follow guidelines and other screening or treatment recommendations. For example, your dot phrase can help you document the screening for sleep apnea using the STOP-BANG questionnaire or guide your treatment for pharyngitis using the CENTOR criteria.
Step #3. Continue to grow your list of templates until you have a comprehensive library of dot phrases.
There are several ways to grow your list of dot phrases and templates. One is to carve some time out of your pre-charting preparation. You could review the list of patients you will be seeing in clinic and spot a few of the conditions you will be dealing with.
Let’s say, for example, that Mrs. Smith is coming for knee pain. This probably will be a patient with knee osteoarthritis. You could then create a dot phrase for each section of your SOAP note (HPI, PE, A/P) to quickly document the knee osteoarthritis visit. Even if Mrs. Smith ends up with a completely different diagnosis, your time will be well-spent because you will now have a dot phrase to deal with any patient who presents with knee osteoarthritis in the future.
Another way to grow your library of dot phrases is by dealing with the creation process after the fact. Let’s say, for example, you are starting to see more and more patients with acne or warts. If you find yourself typing the same note over and over, it’s time to take 10 or 15 minutes to create a new dot phrase.
Developing a list of dot phrases will save you many hours of work completing your medical documentation at night or on the weekends–surely one of the main causes of burnout. At StatNote, our goal is to help our colleagues bring back the joy of practicing medicine by expediting their medical documentation. Ensuring a more accurate, timely and complete medical record will not only help you achieve a better work-life balance, but also could have a positive impact on your revenue.
Take advantage of our extensive library of dot phrases. Make them yours today and tailor your dot phrases to suit your own documentation style.
Do you use dot phrases? Share your experience. What tips and tricks have you find useful to create useful templates? Feel free to comment below.