Here are tips you can borrow to write concise notes. While keeping them clear and thorough. And spending less time on EMR documentation.
Don’t write paragraphs. You’re not writing a novel. Think bullet lists. They are easier to read.
Cut on pronouns. This is useful when using templates and dot phrases: You don’t need to replace all pronouns.
Use abbreviations. Medical abbreviations are time savers. However, use only approved abbreviations.
Use shorter phrases. Don’t spend time typing a long phrase when a shorter alternative is just as clear.
Use symbols. Symbols add readability. You can insert them quickly with shortcuts using a text replacement tool.
The next tips won’t shorten your notes but will help you spend less time charting.
Don’t capitalize every first letter. Skip the shift key if you’re not good at using it. Lowercase notes are still clear and thorough.
Restrain from correcting all typos. Learn to accept some typos and incorrect spelling. Correct only what needs to be for clarity.
Add periods only when necessary. Use punctuation only if it brings more readability.
Charles Tanguay is a family physician and creator of Dilato, an app to help doctors write their clinical notes quickly using templates and shortcuts.
Image credit: Shutterstock.com
