Even before electronic health record (EHR) use was common, paper templates were developed to help physicians and other clinical staff efficiently document services and used as a reminder of clinical guidelines for certain patient populations. The use of templates in EHR systems has even been promoted through government agencies. For example, under the Agency for Healthcare Research and Quality–funded grant, “Improving Pediatric Safety and Quality with Healthcare Information Technology,” the Partners Quality Improvement Group created pediatric visit templates for the ambulatory environment. These templates were designed to enhance care at health maintenance visits and visits for children with chronic conditions. So why is caution needed when using documentation templates?

Like all tools, templates must be created and used properly to be effective. If templates are difficult to use in practice or limit the ability to individualize documentation, notes may become too standardized, lack unique details of each encounter, and contain...

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