GREAT DOCUMENTATION ON ANY BUDGET
Generating great documentation can be expensive. However, with a little creativity, a computer, and Microsoft Word, users can generate great looking, HIGH quality documentation very easily. Using some of the productivity tools that are built into Microsoft Word, the session will show you easy ways to use templates, macros, and "commonly used" phrases to speed up your document generation. Templates are easy to create, and can be used for many documents, from SOAP notes, to patients’ family and medical history, to X-ray reports, narratives, progress reports, and exams. A “macro” allows a user to generate a commonly used phrase just by typing one word or phrase. For example, type “SLR” and the computer automatically changes it to “straight leg raise”. The session will provide consultation and education to enable users to produce high quality documentation just by using a computer, Microsoft Word and a laser printer.
Going a step further, the next part of the training will include the use of speech recognition to streamline the activities of creating documentation in Microsoft Word. The use of macros, templates and other shortcuts will be covered, as well as using speech recognition instead of typing. Macros can also be used with speech recognition, so when a user dictates “SLR” the computer types, “Straight leg raise”, or say “Pain 8” and the system responds with “On a scale of 0-10, with 10 being worst, the patient states that the pain is rated an 8.”
The training will include a demonstration and instructions on using a digital recorder with speech recognition and Microsoft Word for creating high quality documentation very quickly. A user can dictate into a qualified recorder, and as long their dictation is clear, get excellent recognition and automatic transcription by the computer, at their convenience.
Computer security and making good backups will be discussed and a variety of ways to secure your patient information will be covered. New government regulations (HIPAA) will require you to keep your patient information secure and now is the time to start planning for compliance. You will learn different ways of securing private patient information on your computer so that only authorized users have access to the information. If you use a laptop computer, learn how to keep the patient files encrypted. 300,000 laptop computers are stolen each year. If your data is encrypted, even a thief can’t access your private files!