Should Your EMR Have Templates / Canned Notes?
by Leigh-Ann Renz, 10.02.12 (updated 10.22.15)
"Canned Notes" for Mental Health
Many mental health EMRs and EHRs (electronic medical / health records) have templates, which means that you don’t have to create a note from scratch but can rather add to a pre-existing template that covers the basic structure of the client assessment. There are many pros and cons to templates, also known as canned notes. It’s good to remember that while templates make a lot of sense in general medicine, the world of mental and behavioral health is often much more subtle, both in assessment and diagnosis.
A medical doctor can usually run tests that give a concrete diagnosis, whereas a mental health professional may need more than one meeting with the client to assess and determine diagnosis. Mental health clients may be experiencing more than one condition that can affect your observation and diagnosis, and without concrete testing available, more in-depth notes may be required. Additionally, behavioral health diagnosis is made even more tricky with the advent of DSM-5 and ICD-10.
Behavioral Health Note Templates
This isn’t to say that templates can’t be used in mental and behavioral health; in fact, they can be an invaluable time-saving benefit to your practice. The key is finding the right templates for your specialties or being able to create and customize your own. Creating your own note and treatment plan templates allows you to truly save time by building documents that capture your treatment methods.
You should also be able to customize your templates so that each note captures the specific individual needs of your client, with all the nuances and degrees that mental health charting can include. Perhaps part of the note is repeated, but the ability to add the customization needed for medical necessity - to support the CPT code and therefore reimbursement - is a must.
Ask to See Note Flexibility and Templates
If you’re shopping for an EHR, ask potential vendors to demonstrate the format of their notes. Ask about templates: if you can create them, how difficult it is to do so and how templates and notes can be edited or tweaked as you use them. You should always request a free 30-90 minute demo of the systems you are seriously considering and see the program in action, with the opportunity to ask questions throughout. Be sure that notes and any templates are a part of the demos you participate in, as this is a very vital portion of your therapy session.
How does PIMSY handle note templates?