Streamline your EMR documentation

If your orthopaedic practice has not yet adopted an electronic medical record (EMR) system, such a purchase is probably in your future.

Whichever EMR system you adopt, you’ll find that using an EMR affects the way you interact with patients and document the patient encounter. If you use a paper chart, you probably write your notes (or dictate and have them transcribed) after the patient encounter. With an EMR system, you generally enter, save, and retrieve the digital information in real time—during the patient encounter. Although many EMR systems include templates that are supposed to help speed the process, the EMR-generated note is generally insufficient for orthopaedic documentation.

“In our practice, referring physicians, my partners, and I have seen substantial limitations in standard EMR-generated notes,” said William J. Mallon, MD, of Triangle Orthopaedics in Durham, N.C. Consequently, Dr. Mallon and his partners—like many other orthopaedic surgeons—have developed orthopaedic-specific narrative templates.

“Narrative templates can solve the challenge of creating text-like notes that look like a typical doctor’s note with all the necessary information,” he explained.

But creating all those templates is very time-consuming. That’s one of the reasons the AAOS Electronic EMR Project Team is introducing the electronic Patient Encounter Narratives (ePEN).

ePEN pluses
The ePEN templates can help reduce the amount of time you spend creating narratives by providing access to a library of customized narrative templates developed by your peers. Each of the more than 2,000 ICD-9 codes used in orthopaedic offices will have at least one narrative template; some codes may have up to five choices. Templates will cover patient encounters for all evaluation and management (E&M) services, consultations, history and physical, diagnoses, imaging procedures, and surgical procedures.

Plus, by using the unique narratives for each combination of ICD-9 code and type of patient visit, you’ll be able to reduce the risk of “cloning” the note from the previous visit. According to many medical liability attorneys, simply cloning notes presents problems, particularly if an adverse event does occur.

Narratives are based on a SOAP (subjective, objective, assessment, plan) note format for each orthopaedic condition. Using the narrative templates will also eliminate the need to put everything in every note.

Try it out!
Complete information on the ePEN program is available at the Practice Management Booth in Academy Row, Sails Pavilion, near the AAOS Resource Center. You can view a live demonstration and learn more about the program.

After the meeting, you can purchase a 1-year subscription to the ePEN templates online at the AAOS Web site. A single subscription per office gives every physician in the practice immediate 24/7 access to the entire library. You can modify downloaded narratives created by others and customize the note for use in your EMR system, or submit your own customized narratives.

Prepared by Jackie Ryan, practice management program coordinator.