The autocorrect dictionary in your EMR can be used to significantly increase the speed of your documentation. This is the tool that corrects inadvertent mis-spellings. For example, “paitent” would be automatically corrected to “patient.” However, this tool can also be used to change letters into words and short phrases. This can allow you to create a type of shorthand which minimizes the number of keystrokes needed when documenting. Common examples of this include “pt” becoming “patient” and “hx” becoming “history.” If there are multiple two-letter abbreviations that you commonly use, you can distinguish them by making one lower-case and the other in CAPS. For example, “pt = patient” and “PT = physical therapy.”
The autocorrect dictionary can also be used to create entire phrases from just a few keystrokes. For example, I found that I was constantly typing the phrase “…who presents to the emergency department for the evaluation of…” Using the autocorrect dictionary I can turn this into the 3-letter shorthand “wpt.” The current build of Epic that I use allows me to create phrases up to 64 characters in length.
Using some of the autocorrect shorthands that I’ve created, here is a demonstration of how powerful this feature can be:
“Mr. Smith is a 46yo m waho htn, cad, dm, and chf, wpt cp. Hdp as a “pres” sen that does not rad. Pt rtp as 7/10 in sev. The pain is exac w exer. He den f, c, n, v, or sob. Pt den hhs.” (188 keystrokes)
“Mr. Smith is a 46 year-old male with a history of hypertension, coronary artery disease, diabetes mellitus, and congestive heart failure who presents to the emergency department for evaluation of chest pain. He describes the pain as a “pressure” sensation that does not radiate. Patient rates the pain as 7/10 in severity. The pain is exacerbated with exertion. He denies fever, chills, nausea, vomiting or shortness of breath. Patient denies having had symptoms like this in the past.” (481 keystrokes)
In this brief example the autocorrect dictionary decreases the number of keystrokes from 481 to 188 keystrokes. This is a 61% decrease in the number of keystrokes used to create the same document. How does this translate to real world benefit? If it takes you 10 minutes to complete a typical chart, implementing this single change to your documentation would save you 4 minutes per chart. If you see 20 patients on a given shift this would free up 80 minutes! How would you spend those additional 80 minutes that you gained?
If you decide to implement a shorthand system such as this using the autocorrect dictionary you will find that your charting will actually be slower than usual when you start using it. This is because you will frequently have to stop and recall the shorthand abbreviations that you had created. Before long, though, the muscle memory will kick in and you will start using the abbreviations automatically.
Do you already use your autocorrect dictionary to speed up your documentation? Have you found it to be helpful? If you have any additional autocorrect tips and tricks to add I’d love to hear them.
If you’d like a spreadsheet with the autocorrect abbreviations that I use in my own documentation just email me at email@example.com and I will send you a copy. Please write “autocorrect dictionary spreadsheet” in the subject line.
(note that the specific functionality of your autocorrect dictionary will differ depending on the particular EMR that you are using. The examples that I provide here are specific to Epic)