Typing a meaningful note takes time that most physicians do not have. Alternatively, using the shortcut tools built into EMR software produces poorly-worded, awkward, and risky results. Using large blocks of boilerplate text that require manual editing is also risky and prone to error; forgetting to change an important detail can later be costly. The EMR has provided new opportunities for malpractice lawyers, and the problem is growing (just do a web search on EMR and malpractice). Speech recognition software is also cumbersome to use and is often unreliable.
Created by a psychiatrist/programmer, Clinical Scribe is a note writing tool that can be used with any EMR and builds meaningful DSM-5* criteria based symptom documentation, forming the backbone of your history. It does what dropdown menu-based tools cannot accomplish: it allows logical branching based on your selections, so the end result is well-phrased and to the point, without the need to clean up leftover unused dropdown menus. You can navigate meaningfully but swiftly through the menus to cover necessary items. Templates are included for the most commonly-used disorders (both new and follow-up notes), and additional templates can be added upon request. Other components include all standard sections of a clinical note, including mental status examination and physical examination, to efficiently handle the routine components so you can focus on the symptom context and case formulation.
Click here for more information and a free trial: textBEAST Clinical Scribe.
After trying the included templates, please contact us if you would like assistance in the development of custom templates for your practice.
*All DSM-5 content reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders™, Fifth Edition Copyright © 2013 American Psychiatric Association. All Rights Reserved.