I've been working with an electronic health record system, or EHR, for five years. One of the best things about an EHR -- in this case, AllScripts TouchWorks -- is the ability to make detailed structured progress notes that automatically saves the CCR (Continuity of Care Record). Any provider using Touchworks can import this data into the next progress note.

It's a huge timesaver not having to rewrite a personal history or medication list every time a patient comes in. And TouchWorks allows me to create a very thorough and legible progress note while minimizing time spent. I can even finish notes from home, if necessary.

In TouchWorks, you can make two types of progress notes, unstructured (purely typed note on a blank page with no CCR information used or created) and structured. I'd like to describe the workflow I have found to be the most efficient for creating a structured note, which I do using a mix of citing, manual typing, voice recognition (VR), text boxes, text templates and MEDCIN findings.

First, I start the note by clicking on the patient name in the TouchWorks Schedule Module, making a mental note of what the appointment is for as noted in the appointment comments.

I have TouchWorks set up so that the program automatically recalls active problems, current medications, allergies, personal history and results from the last 30 days. If the visit is for a physical, I manually CITE the past surgical history (PSH), family history and immunizations, too.

I bring the patient into my office or exam room myself. I open a text box in history of present illness (HPI) and do some simple typing of key points as I take the history, keeping as much eye contact as possible with the patient.

I will click on the meds tab and go through each medication, discontinuing, changing or adding as needed. I'll return to the note and CITE the meds again, which will update the list to show exactly what they are taking. If the patient is not on any medication, I use a text template to indicate that.

For changes or additions to personal or family history, I always use the FINDINGS button and the templates I have created for these categories. (Feel free to look at mine, with names starting with "JWW.") I keep the top six to eight general MEDCIN findings in my templates and simply alter the details with the plus (+) or minus (-) buttons. After clicking SHOW DETAILS, pertinent information is put in the TEXT field. This keeps it quick and simple and allows those details to show up in the notes.

For review of symptoms, I have a comprehensive template that I use for physicals and pre-ops. I start by pressing the blue (-) button so that each symptom is marked as negative/normal. As I go through each symptom, I change the minus to a plus where applicable and make a note in the TEXT section. Those text notes then appear next to positive/abnormal symptoms.

If taking a surgical history, I will use the SEARCH button after clicking ADD in PSH. It is amazingly easy to find the right surgery with a few key words. Specifics can be added in the details section. For the date, I just enter the year it was done or month and year if known.

All of this is done manually in front of the patient and is less distracting than you might think, especially after you become proficient.

Beside my exam table, I have a second monitor, wireless mouse and wireless keyboard attached to the same computer I have been using at my desk. As the vitals machine is doing its thing, I pull up the vitals screen then manually enter the respiratory rate, temperature, blood pressure and pulse. (You or an assistant can use Internet Explorer to import vitals from a Welch Allyn machine, but I prefer to use CITRIX, which does not allow the importing of vitals.)

Before the patient leaves, I send prescriptions through SureScripts directly to the preferred pharmacy and select POST TO NOTE. I give them handwritten orders for labs and X-rays. But before calling in the next patient, I click on the plan section and use a text template to document all common things I ordered so I don't forget, especially the vaccines. My medical assistant will administer and document the vaccines. I dictate uncommon orders later.

After I have finished all the patients for that session or day, I will then use my Dragon NaturallySpeaking VR program and go back to the first note of the day. I'll click on the text in progress for the HPI and then dictate a full HPI while referring to the brief notes I manually typed earlier. It is all visible right there in the same text window. I just highlight and delete those notes once the dictation is done.

Truthfully, I don't bother proofing the voice recognition text. The few mistakes it may make on occasion are easily figured out phonetically if I read the note again. But if I want the note just perfect, like for a pre-op, I'll proof it right then and edit with voice recognition or manually.

I document most normal exam findings with normal text templates. I'll then dictate abnormal findings in a text box or edit the normal template with VR. (Using the MEDCIN findings here is too cumbersome.)

Lastly, I go to the active problems, highlight the relevant ones, check POST TEXT TO NOTE and ASSESS them. I'll return and add a free text assessment for acute problems or discussion. I'll add a brief free text dictation of the plan if needed, including follow-up.

Then I'll sign the note, click on MD CHARGES button and add the office visit code or other charges.

And that's how I create and use structured notes. Hopefully you can get some good ideas from this. I would love to hear any suggestions you have, too.

John W. Wilson, M.D., is a Brown & Toland family physician in Daly City. Contact him at jwwilsonmd@aol.com.