University of Tennessee College of Medicine, Semmes Institute drop down template
Brandon Baughmann, Ph.D., contributed the template. He also supplied some history of how it was developed that might be helpful to other groups:
In our clinic, neuropsychologists have dictated and had their notes transcribed into word, then scanned and uploaded by the secretary into EMR. The process was cumbersome and often the referring physicians within the clinic (~30 neurosurgeons, 5 neurologists, 3 physiatrists/pain management), would miss the neuropsychological assessment note because it would show up as a non-specific attachment.
Over the past six months or so, we have moved to the option of being completely form-driven on EMR, with the exception of forensic/medicolegal cases. We have a fairly well-staffed IT/EMR department, so the director was able to sit down and custom design our “neuropsych note” and various form. The clinic uses GE Centricity (Practice Solution 10). Because the design can be fairly complicated, our EMR director indicated it would be much easier for me to sit down and give her what I wanted and then let us work out the kinks. I’m happy with the product so far. It is a single encounter note with 9 separate forms – HPI, ROS, Past histories (2 forms – personal med, family med, and psychosocial), Med Review, Neurodiagnostics, Behavioral Obs, NPsych Test Battery, and A&P. With the exception of the HPI, A&P, and certain sections of behav. obs, the forms are pretty much drop-down or radio-button driven.
Since the note is up and running, I’ve seen a considerable improvement in my report turnaround time. I’m working on a process such that our neuropsych assistants can input parts of the history (e.g., ROS, PMHx, etc.), which is what the nurses will often do for the physicians in the clinic. That would most likely shave an additional 10-15 minutes from the report.