Doc-U-Chart Paper Template Charting System — Frequently Asked Questions (FAQ)
- Are forms adequate documentation?
- Does the doctor pick which form to use?
- Where are the forms kept?
- Who completes the forms?
- What's the best way to get started?
- What help is available?
- How do I decide which form to use?
- What are the PFSH Templates?
- When do I use the PFSH Template?
- Doesn't the chart get thick using a piece of paper for each visit?
- What about patients with multiple problems?
- What if my charts turn left to right rather than flip up?
- Why is only part of the ROS on the front of the form?
- Why are the templates in columns?
- How do I chart phone calls, refills, or other chart notations?
- How will my templates be personalized?
- What if I need something added to my forms?
- Can I duplicate the forms?
- Can forms be provided for a group practice?
- What if I want some specialized templates?
- Are there extra fees, annual fees, or any licensing fees?
- What computer system do I need to user the forms?
- How do I print the templates?
- What if I don't have a computer?
- What if the computer files are changed?
- It seems too easy. What am I doing wrong?
Are forms adequate documentation?
Yes. The use of forms and templates has become an accepted medical practice. The JCAHO has approved the use of template forms by physicians in
Emergency Room and other outpatient settings. The important point is that the completed form must accurately and legibly reflect the care provided.
The template does not replace a properly performed history and physical exam, but ensures that the service is quickly, easily, and completely documented.
Does the doctor pick which form to use?
Usually the nurse or assistant interviews the patient to find the chief presenting symptom and then picks the appropriate template. In practice, they will
occasionally need the advice of the physician to help choose the correct template.
Where are the forms kept?
It is recommended that an ample supply of all templates be kept on hand, usually at the nurses station. Some physicians have opted to keep the templates in
the exam room. Office personnel should be responsible for printing and refilling the folders as the templates are depleted. As part of the purchase, Doc-U-Chart™
supplies ready made adhesive labels and instructions for creating a hanging file folder system to make storage and organization of the templates a snap.
Who completes the forms?
The templates should be completed and signed by the physician. However, the nurse or assistant usually documents the chief complaint, pertinent aspects of the
HPI, and vital signs. Doc-U-Chart™ suggests that, outside the chief complaint, narrative on the templates be left to the to the physician/provider. Since
space is a premium on the templates, this helps ensure that only truly relevant data is recorded.
What's the best way to get started?
It is usually best to start with only a couple of templates for a week or two. This gives the nurse or assistant and physician time to learn the
layout of the template and develop a “comfort level” for coding the templates. The General Exam and Respiratory Symptom templates are
good ones to start with.
What help is available?
We are available to answer your questions at 903-579-2710 or 903-561-7096. We can also be reached at this Web site. Just click here.
For larger group practices, in-service training is available.
How do I decide which form to use?
The templates are generally symptom specific. In addition, they are made more specific according to age and sex. For those patients whose symptoms are
somewhat nebulous, the age and sex appropriate general exam templates fit the bill nicely. In general, use the template that seems best suited to the
patients current symptoms.
Doc-U-Chart™ suggests that the nurse or assistant choose the template, being careful to ellicit the symptoms from the patient. Chief complaints such
as “wants Ritalin”, “needs pain med”, “needs referral”, or “wants X-ray" are not symptom specific. Contrast these
with “seems hyper”, “recurring headache”, “bad rash”, or “ankle pain".
What are the PFSH Templates?
PFSH is an acronym for Past, Family, and Social History. The PFSH templates are comprehensive reviews of these history areas. These templates are
specific for gender and age (adult, adolescent, child, and infant and toddler.)
When do I use the PFSH Template?
Although all Doc-U-Chart™ templates have a condensed version of past, family and social histories, a more comprehensive history review is found
on the PFSH template. This template should be used one time for all patients whose history has not been previously and clearly documented, preferably at
the initial visit or at the time of a complete physical.
Doesn't the chart get thick using a piece of paper for each visit?
Look at the thick charts in your practice. Most likely they are thick because of lab work, correspondence, and other old records. For most patients, who are
seen in the office two or three times a year, the patient care record is very manageable. For patients who are seen more often, the legibility and organization
of the Doc-U-Chart™ system more than make up for the few extra sheets in the patients record.
What about patients with multiple problems?
All symptom-oriented templates contain history areas on the reverse page for documentation of additional problems. For complicated patients, the General
Exam forms provide additional space for the documentation of multiple problems.
What if my charts turn left to right rather than flip up?
Templates are available for this format.
Why is only part of the ROS on the front of the form?
The templates are optimized for one page completion. 75% to 80% of most office visits are level 3 or less. These levels can all be coded on the front page
of each of the symptom oriented templates. This one page display also allows quick scanning for pertinent information when reviewing prior visits.
Why are the templates in columns?
Think about newspapers and magazines. The eye scans and records items more quickly and thoroughly in the column format. This format also allows rapid
scanning of the record for completion and review.
How do I chart phone calls, refills, or other chart notations?
The Doc-U-Chart™ System includes a template for personalized Progress Note pages. Like the Exam templates, the Progress Notes are in column format,
which helps the flow of the chart. What little dictation that is left is printed in column format (an easy task for the transcriptionist's word
processing program) and put on the either the Subsequent Note section of the template or the Progress Note page.
How will my templates be personalized?
Templates can have your name, clinic name, address, and/or phone number. It generally looks “cleaner” to have the Physician ID box (in the upper
right hand corner of all forms) contain the provider name and one other line of information. However, by reducing font size, lots of additional information
can be added.
What if I need something added to my forms?
For an additional fee, some changes (e.g. specific patient instructions that a provider commonly uses) can be made on the templates to accommodate your
practice style.
Can I duplicate the forms?
Yes, the purchaser is licensed by Doc-U-Chart™ to copy or duplicate the templates for personal use. However, all Doc-U-Chart™ products are
copyright protected. Like other software, it is unlawful for the system to be used by anyone other than the purchasing provider without license from
Doc-U-Chart™.
Can forms be provided for a group practice?
Yes, if a medical group desires a set of templates for clinic-wide use, they can be provided with the group name and the individual physician's name.
Because of the variation in legibility of physician signatures, it is important to have each individual physician's name printed on the form.
What if I want some specialized templates?
Doc-U-Chart™ is in the template business. If you have special needs, we would be happy to have a chance to discuss creating a template system that
meets your needs. This type of work is done on a contractual consulting basis. Please contact us for more information regarding consulting fees and contract
arrangements.
Are there extra fees, annual fees, or any licensing fees?
No! The purchase of the templates entitles that physician or practitioner to the unlimited use of the templates in the personal practice of medicine for
eternity! However, this license does not extend to a physician's colleagues or to employees such as PA's or Nurse Practitioners. As providers of Medical
Services, associates and employees must have their own set of forms or have the licensing fee (i.e. purchase price) paid on their behalf to allow them the
right to use the templates.
What computer system do I need to user the forms?
Most modern computers will enable printing of PDF files. If you do not have the free program Adobe Acrobat Reader, you can download a free copy by clicking
the link below.
How do I print the templates?
There are several ways to mass produce templates. You can use your printer to do all the printing, or they can be printed and then reproduced using
a copier. A little bit of practice will determine which method works best for your practice. The printer-generated templates, however, are the sharpest
and best looking.
Many practices will find it economical to purchase a double-sided printer for printing the templates. For the difference in quality and ease off
reproduction, the double-sided printer is worth the expense. In networked systems, a single double-sided printer can be used for the print jobs of all
the providers. Even if you are only a modest user of dictation, savings from switching to the Doc-U-Chart™ system will pay for the new printer
quickly.
What if I don't have a computer?
Sorry, but we no longer provide card stock originals. Perhaps it is time to invest in a computer, or you can have a printer print your templates for you from the cd.
What if the computer files are changed?
PDF format files cannot be changed by the user. You can read and print your files, but you cannot edit them. This prevents inadvertent corruption. If your
files are somehow lost or damaged, you can be supplied with a new set for a replacement fee of $100, which includes shipping and handling.
It seems too easy. What am I doing wrong?
Probably nothing! Remember, the goal of the Doc-U-Chart™ system is to make charting quick, accurate, and painless! It is designed to free the
physician from the burden of charting and is much faster than writing or dictating. Look over the completed template to be sure it accurately reflects
the services performed, and check the coding against the required criteria. You will soon learn that you are doing a better job of coding in a fraction
of the time and at a fraction of the cost!
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