Most EMR's allow for certain boilerplate things to be inserted easily. My wife is a neurologist; it's very common for her to dictate a note saying "insert seizu

Most EMR's allow for certain boilerplate things to be inserted easily. My wife is a neurologist; it's very common for her to dictate a note saying "insert seizure precautions" and it puts in a paragraph of things that you can't do if you have seizures: take a bath, drive, get on ladders or other elevated surfaces, that sort of thing. I've customized the hell out of my own hospital's Epic system (I'm an anesthesiologist) to make notes as easy as possible. 95% of the things I do are done the same way, every time. Back when we used paper, they had all of that in checkboxes on forms. Basically a way to say "yes, I did this legal and proper" very quickly. It was very useful because you knew that if you skipped over that and went straight to the written description on an old record, you'd actually get the important information. Before billing criteria took over medical documents, doctors could do more because a board-certified pediatrician doing a well-baby visit could just write "18 mo WM, PMH NC, PE WNL, f/u 6 mo" (18 month old white male, past medical history noncontributory, physical exam within normal limits, follow up in six months). We had "skeletons" for reporting the most common labs in notes - just a graphic representation so you didn't have to write "Sodium 139, potassium 4.3, chloride 122, bicarb 24, BUN 9, creatinine 1.1, glucose 85". 139 | 122 | 9 / --------------- 85 4.3 | 24 | 1.1 \ The paper medical record was subject to handwriting, but it was extraordinarily space- and time-efficient.