The increased requirement of keeping comprehensive patient treatment records/SOAP notes can be burdensome on a doctor's time and energy. While there are many commercial software programs on the market that are specifically deigned to provide a rapid charting of patient records, I have found that Microsoft Word™ can be tweaked to create rapid, detailed, and accurate chart notes. Not only is this system economical since most offices have Word™, but it can also be customized for each specialty and each individual provider.

This system of speed notes uses the Word™ feature of AutoCorrect. AutoCorrect is typically used to correct commonly misspelled words. This feature can be used to greatly increase a doctor's ability to rapidly document. Word™ comes pre-loaded with commonly misspelled words and typing errors. If you type "teh", AutoCorrect will automatically change it to "the". Another way to use AutoCorrect is to "teach" Word™ to recognize abbreviations and replace them with text, pictures, charts, or tables. For example when I type the letters "caromn" (cervical active range of motion-normal) my computer autocorrects that abbreviation into the following table:

If I type "DTR", my computer autocorrects that abbreviation into:

Deep tendon reflexes: Achilles +2/+2, patella +2/+2, radial +2/+2, biceps +2/+2, triceps +2/+2

If I type "bx", the following picture is inserted into my document:

I have dozens of autocorrect abbreviations that create everything from individual words to exercise programs, neurological examinations, and anatomical illustrations.

How to "Teach" AutoCorrect to Recognize Your Prompts

1. Type the phrase that you would like to enter as a speed note. You may also generate a chart or place a picture into the Autocorrect feature. Note: Some early versions of Word™ may limit the number of characters that you can use with the Autocorrect feature.

2. Highlight the test or object(s) by clicking the left mouse button and dragging the mouse over the item. It should appear blackened as the item in this illustration looks.

3. Click on the Tools menu and click on AutoCorrect.

4. Select an abbreviation that is appropriate. Keep your abbreviations simple and avoid commonly used initials or misspellings. I like to use two to three letter abbreviations with the letters X and Z in my abbreviations to avoid having autocorrect insertions mistakenly appear in my documents when I have made common typos.

5. At this point, I recommend that you select Plain text for word insertions and Formatted text for charts and pictures . Selecting Plain text will automatically produce your phrase in the formatting of the document in which you insert your abbreviation.

6. Click the Add button.

7. Select the Replace text as you type preference.

8. Click the OK button.

9. Now when your abbreviation is typed into the document, it will insert your item when you push space, enter, or insert punctuation.

10. To remove an unwanted insertion hit undo.

Practical Pointers

Our goal in using Word™ for creating speed notes is to record information rapidly and accurately. One of the risks that we face is creating cookie-cutter patient care notes. We need to avoid notes that look the same from patient to patient. Here are a few pointers to maximize your efficiency and accuracy.

For the "Subjective" or history portion of the notes, record each patient's complaints accurately and specifically. You may have to use abbreviations of specific words or phrases to speed this process, rather than using big blocks of words. This portion of the chart notes must reflect the patient's version of his/her ailment.

For the Objective, Assessment , and Plan portions of your chart notes you can use larger blocks of words, phrases, and charts. If you record your exams with normal findings in your AutoCorrect file, do not forget to amend any positive findings that need to be changed. Delete any tests or examinations that were not performed.

Print your notes after every visit, but save your chart notes on your computer. On subsequent visits re-address the positive findings. Delete portions of the office visit that were omitted in follow-up visits.

Use the automatic date stamp feature of Word. Create a text box, left click in the text box, then push Shift-Alt-D . This will create a date stamp that automatically maintains the correct date. You can even use the AutoCorrect feature to store your date stamp.

Samples

Here are some samples of the abbreviations and AutoCorrect phrases that I use. I recommend that you customize your template to reflect your own phrases and memory cues.

Here are some examples of some bigger charts and pictures that I use:

mmtue

mmtle

carom

abex

Aps4

rpx

tpx

Conclusion

Virtually any commonly used phrases, words, charts or pictures can be easily recorded into AutoCorrect. This tool can save time and make your chart notes neater, and more explanative. Use your creativity to generate your own list of AutoCorrect texts and abbreviations. Please feel free to e-mail any ideas that you may have on creating fast and accurate chart notes.