“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #166

Medical charts, patient charts

Charting and documentation are one of our most dreaded yet MOST important tasks as nurse practitioners.  Saving time wherever possible during charting tasks increases our proficiency and even helps us improve our bottom line.  

A “macro” is a large section of the narrative, identified by a short dot-phrase, in some EMR systems.  An example might be related to your diet education, the side effects of a medication, or how to take a med.  Type all that out in a general fashion that is easily applied to all or most instances when you’ll use it.  Then, assign a few keystrokes, like .jgURI. 

For my EMR, I assign my initials to it so that all users can identify it as my macro if it is a “shared” macro.  When typed out, .jgURI becomes a long discussion of OTC remedies and other tips/tricks for managing the common cold.  

Another example is .jgmetsyn; in my system, I use this one often b/c lots of my patients have metabolic syndrome.  Teaching them about the condition in a sentence or two and then adding a few sentences about recommendations provides patients with easy resource material in their visit summary while giving my documentation a professional appearance.  Other macros can provide information designed to protect you by describing safe practices, like recommending mammograms or other tests you’ve mentioned.  

If I verbally teach or type out a few sentences of education once, I evaluate the need for future use of the information and create a macro right then and there to save time and effort later.  For me, it’s all about keystrokes.  Every keystroke costs money; to become more efficient and therefore more profitable, pay attention to keystrokes. 

One Response

  1. I agree! My goal is to create 10 complete templates including exam ROS and MDM for top 10 issues. Can you share your metabolic syndrome and common cold phrases? Also I’d love to hear your thoughts and experiences on reverse dieting…. (Listening to Peter Attia and Holly Baxter so now interest piqued)

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