Charting and Templates
Resident & Student Rotation Templates
Part One: Using dotScribe
1. Can't get your EHR to find the diagnosis you're trying to spell?
Our autocomplete feature can help!
Just start typing medical terms or medication names and press the Execute Key to paste. Commonly misspelled non-medical terms are also included.
PRO TIP: Type without using spaces for more accuracy when searching for multi-word phrases (e.g. type "dequerv" instead of "de querv" for de Quervain's tenosynovitis)
2. Need to document a new problem?
Every template is standardized and includes common findings to increase history-taking speed and accuracy. A "pertinent negatives" Review Of Systems is also included in each template to help you avoid missing key symptoms.
Our free text templates are easy to navigate, work great with dictation software, and reduce stress in case of an audit.
,hpiHm - for Health Maintenance visit templates by sex and age
,hpiDME - for common face-to-face encounters needed for Durable Medical Equipment
,hpiTemplate - for a blank HPI template
3. Need to quickly document a chronic problem or follow up visit?
Need to quickly document a CHRONIC PROBLEM or FOLLOW-UP visit?
Follow-up templates are brief and include a suggested "pertinent negatives" Review Of Systems. Simply document a patient's status and/or adherence to treatment goals and move on. Sometimes less is more.
Consider using these simple templates if your patient has multiple complaints.
,fuED Emergency Visit - for emergency department follow-up template
,fuHospitalization - for hospital follow-up template
4. Need to document a normal review of systems?
These shortcuts consist of NORMAL ROS findings. Each is concise and ready to insert directly into your note. You can also build your own from our full Review Of Systems list: ",rosallnormal"
Remember that all of our HPI and Follow-up templates include a problem-specific negative Review Of Systems. We recommend the ",ros in HPI" phrase under the ROS section in your EHR to avoid redundant work.
5. Need to document a physical exam?
We've created common NORMAL exam findings by SYSTEM as well as DISEASE-SPECIFIC exam findings that are easy to edit on the go. You can also build your own from our full Physical Exam list: ",examallnormal"
6. Need help making a diagnosis or an order set?
Diagnosis shortcuts include common exam findings and initial tests meant to support your medical decision making. They can also be used as a reference to document a physical exam or create order sets within your EHR.
If needed, type the entire phrase or word that you're searching for (e.g. hypertension or hyperlipidemia) to improve search accuracy.
7. Need to review a differential diagnosis?
Immediately increase your diagnostic accuracy without a pause. With these shortcuts you can view the most common differentials for your patient's problems at a glance.
8. Can't remember the CTP billing code for an in-office procedure?
Search no longer! Quickly find your code and billing is done.
9. Is your inbox overflowing with medication refills, patient messages, and results?
Based on hours of experience, we've created hundreds of boilerplate templates to make communicating with patients and staff a quick and simple process. These can be mixed and matched to gain better control of your inbox.
,msg = patient message
,smsg = staff message
10. Love medical abbreviations?
But your billing department doesn't? Or can't understand someone's note because you're stuck on an abbreviation?
We have your solution. Simply access the most commonly used medical abbreviations with a comma.
11. Use a single line or sentence all of the time?
Individual lines from our templates can be called up like a LINE in a play. This abbreviation was created for all the odds and ends type of phrases that don't quite fit anywhere else.
Part Two: Rapid Links
Quit wasting time searching for information on a browser! Use dotScribe to search only trusted medical websites so you can find what you need as soon as you think of needing it. Web search can easily be performed while typing in your EHR.
dotScribe's unique search engine provides unprecedented speed in delivering the resources you need. Deactivate folders of unwanted websites to optimize your search results.
*Web search function varies when using a remote desktop
12. Want to review medication dosing, indications, or side-effects?
Now you can have every medication instantly at your fingertips! Individual accounts may be required.
13. Need to search your favorite online mesdical resources?
Instantly search topics on UpToDate, Medscape, Epocrates, DynaMed, 5MinuteConsult, and Merck Manual Professional with a short character phrase. Individual accounts may be required.
14. Want to see medication rankings for a medical condition to best treat your patient?
Rapidly find what medications have worked for other patient's medical conditions.
15. Need to print a patient education handout for exercises or a medical condition?
Never let your patient leave without trusted information again. Resources are available from familydoctor.org, OrthoInfo by the AAOS, UpToDate, Merck Manual, Mayo Clinic, and 5MinuteConsult (individual accounts may be required).
16. Looking for a medical calculator?
We've got you covered. Calculators are available from MDCalc, Medscape, and UpToDate (account may be required).
17. Need to review a procedure? Or a special test for a physical exam?
Just type a short phrase to find an instructional video or How-To guide and you'll be ready for action in no time!
Online videos of how to perform Special Tests on physical exam can also be searched by using the ",proc" prefix.
18. Unsure what imaging to order?
Help is at your fingertips! Radiology resource searches include Medscape and American College of Radiology.
19. Want to discuss anatomy with your patient?
Anatomy search results come from Medscape and KenHub (account may be required).
Part Three: Customize Settings
Get the most out of dotScribe with customized settings.
20. Deactivate unused folders
dotScribe templates come in 3 forms based on placeholders found in common EHRs. We recommend using the "Charting With Spaces" folder if your EHR doesn't utilize placeholders. Deactivate the "Charting With" folders that you won’t use to prevent redundant suggestions.
FOLDER TEMPLATE TEXT / PLACEHOLDER Example
Chart With *** Patient presents with *** and ***
Chart With __ Patient presents with _ and _
Chart With Spaces Patient presents with and
You can increase the accuracy and speed of dotScribe suggestions by deactivating folders you don’t use. Simply click on the folder icon to activate or deactivate a folder. When you're done making changes - click SYNC to save your preferences to the cloud.
21. Customize your "execute" or "confirm" key
Settings allows you to control how many suggestions appear, where your suggestions appear, and the key you prefer to select a suggested phrase.
ENTER is the default Confirm Key but we recommend changing this to avoid interference with other programs. Left Shift has been a popular Confirm Key among users.
Click Apply to save changes. Click Sync to store your settings in the cloud.
22. Turn dotScribe's suggestions off and on
Want to turn off PhraseIt suggestions?
Press CTL and Click the PhraseIt taskbar icon to turn suggestions off (icon turns gray).
CTL+Click again to turn suggestions back on (icon turns green).
23. Import your own files from Excel or CVS
It's easy to import your templates and phrases into dotScribe. First, ensure your Excel or CSV spreadsheet has the exact column labels in row 1 as shown below.
For now, CSV files can only be imported on the desktop. SYNC must be performed to save imported content.
Excel files can only be imported online.
24. Add a new phrase
Select the folder that you'd like to create a new phrase in and click Add Phrase. Type or paste text into the New Phrase window, designate an abbreviation, click Save, and you're done! Phrase Descriptions and Tags are optional.
To create a phrase that opens a web page, just paste the link into the New Phrase window (link must begin with either "www" or "http"). Assign an abbreviation and click Save. Selecting the phrase will now open your web link.
SYNC MUST BE PERFORMED to save any new content or changes.
Sync may take several minutes but can run in the background when dotScribe is minimized. A pop-up message will alert you when Sync is complete.
25. Custom folder prefix
dotScribe allows you to easily set a custom prefix to all the phrases within a folder. Click on a folder to view the Folder Options window. Just type your desired character or prefix in the Prefix field (e.g. "." or your initials).
26. Instantly find what you need
There are many ways to browse and search your dotScribe library.
Phrase suggestions are by far the fastest way to search content. Refer to the dotScribe Prefix Legend to instantly access anything you need. It's just that easy.
Press ALT+SPACEBAR at the same time to open the dotScribe Search Bar. There's also an option to open the search bar on the dotScribe taskbar menu. The Search Bar is a classic search of your entire dotScribe library.
Right click the dotScribe taskbar icon to browse your dotScribe library. Phrases are activated with a left mouse click.
27. Browse and Search Content
dotScribe content can easily be viewed and organized within folders by clicking the arrows at the top of each column.
Use the search window to search for tags and terms within a folder.
Thank you for using dotScribe!