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Medical Note Templates


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Hey guys,

 

I can only speak for Ottawa as that is the only place I have practiced medicine but here, almost everyone uses templates for admission notes to save time and to increase the readability and uniformity of note-taking.  I had to get my templates from physicians in the hospital who had them saved in their email. There doesn't appear to be a template sharing mechanism so that the field experts can pass them along to new trainees.   

 

I was wondering if this practice is widespread?  

 

I got tired of having to get them from my email and only having access to templates I was directly given so I created a template sharing website - medtemplates.com

 

Figured I'd post it in the hopes that it may help some of you.  The website is also very new and I would love any advice you guys have to offer.  Or you can send some templates for upload!  

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Sounds like things are run very differently in Ottawa than in Halifax. No standard template for admission notes. Everything is hand written in the chart. There really is no good mechanism in place should you want to use a template, as all the paper has barcodes which place it in the correct section of our "EMR" (which is only scanned in after discharge, and is a poor excuse for an EMR). Always cool to see how things work in other centres. Thanks for sharing.

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  • 3 weeks later...

Sounds like things are run very differently in Ottawa than in Halifax. No standard template for admission notes. Everything is hand written in the chart. There really is no good mechanism in place should you want to use a template, as all the paper has barcodes which place it in the correct section of our "EMR" (which is only scanned in after discharge, and is a poor excuse for an EMR). Always cool to see how things work in other centres. Thanks for sharing.

 

HPF is the worst EMR in existence. On the other hand, I found the Ottawa systems kinda slow and clunky. Meditech may be old, but there's nothing in existence that's faster or more efficient. Though we still hand-write everything otherwise. 

 

If I can offer a suggestion, please provide a list of abbreviations at the end of each template.  For things like HPI maybe not, but I can't figure what RFR is.  Thanks for the website though, it could be really useful!

 

RFR = Reason for referral

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