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You can use your word processing program to create notes almost instantly - even if you're not a great typist.
Having your encounter notes completed and in the chart before the patient leaves your office might sound like a fantasy, but it is typical in my practice. The key to my efficiency is the word-processing technology of macros, which I use as I document patient visits at the point of care.
Macros allow you to record and replay a series of typed characters or other keystrokes. They make it possible for a physician to quickly document an entire medical note while avoiding the cost of transcription or expensive medical-record documentation programs.
Built for repetition
The fact that medical notes often contain repeated information makes them a natural fit for macros. By using macros, you can program a " hot key" (one or more keys hit at the same time) to recall all that repeated information and then simply edit that general note to apply to the specific patient. For example, I have written macros that insert the complete wording for a Pap smear, a routine physical or an infant's two-month examination. Macros can also be used when a patient has a specific complaint. For example, the history, exam and treatment for pediatric otitis media are often very similar.
Along these lines, I have a macro for otitis media that "plays" when I press two keys: "Alt" and "O." After keying in that combination, this is what appears in my word processor's window:
History: Two days of low-grade fever, nasal congestion and pulling at ears.
Exam:
General: Alert.
HEENT: Mild nasal congestion. Mouth normal. TMs are red and dull.
Heart: Regular rate and rhythm without murmur.
Lungs: Clear to auscultation.
Abdomen: No liver or spleen enlargement. Nontender.
Skin: No rash.
Extremities: Normal.
Assessment: Otitis media.
Plan: Amoxicillin, 250mg/5cc, 1 teaspoon three times per day for 10 days. Follow up in two weeks. Report reaction to medication. Report worsening.
With that as my starting point for a typical history of otitis media, I then edit each note as it applies to the specific patient.
How it's done
Here are step-by-step instructions for programming macros in Microsoft Word. (I'll use the example...