Macro templates are time-saving devices that allow the user to assemble the medical record rapidly by prefabrication of large areas of a chart like a normal physical exam. Use of the macro implies the provider did all the items stated. The problems arise when the macro is used (copy and pasted) and some of the data is not normal. This behooves the practitioner to adjust the macro and remember to resolve any inconsistencies in the chart. It is easy to find records where a question is answered yes in one area and the no in another.
Copy and Paste techniques can easily take prior commentary or notations and use them as a real-time note to save time. The medical record becomes an endless story of identical reassessments. The provider has turned the original data into a potential clone of a clone etc. The end result is a “cookie-cutter” chart which is “computerize”. Look at 20 chest pain charts and decide if they represent a real patient or a clone of a computerized generated patient.
Xpress TechnologiesElectronic Health Record uses a proactive approach. The provider can create favorite saying and lists of commonly used verbiage. In addition, XpressChartsallows the provider to easily add real-time context by typing or Dragon (voice activated technology). The result is a chart that is assembled proactively rather than reactively eliminating potential context errors. The result is a record that reflects reality.