Simplify Your Documentation with dotScribe's History Templates

Simplify Your Documentation with dotScribe's History Templates

In the demanding world of healthcare, every minute counts. That’s why we created dotScribe - to make your documentation faster, easier, and more accurate with our standardized history templates.

Quick and Comprehensive History Taking

Taking a patient’s history is crucial but often time-consuming. dotScribe’s history templates streamline this process by guiding you through each step. Our templates cover hundreds of common problems and complaints, ensuring that you gather all necessary information efficiently and thoroughly. It's like having your class notes in your patient notes! Open dotScribe and type "template.history" to see the many open-ended (blank) history templates we have to offer. 


All of dotScribe's History Templates follow this standardized structure:

{Problem}
- Onset was *** ago, due to ***
- Symptoms described as *** {most common symptoms for the complaint}
- Occurs ***
- Severity is ***
- Aggravating factors: *** {prompts for relevant factors}
- Alleviating factors: *** {prompts for relevant factors}
- Associated ROS: *** {systems-based specific positives to help improve your differential and diagnosis}
- Negative ROS: No *** {problem-specific negatives and/or red flags that should not be missed}

- Associated medical history: *** {prompts to ask about pertinent/related conditions or medications to help enhance your differential and diagnosis}
- Associated social history: *** {prompts to ask about lifestyle and other factors to help narrow your differential and diagnosis}
- Associated sexual history: *** {prompts included if pertinent to the complaint}
- Associated family history: *** {prompts included if pertinent to the complaint}

Please note:
  • dotScribe's placeholders (***) and {brackets} can be changed in dotScribe's desktop settings to match your EMR or dictation preference.
  • Pressing the F2 or F3 key in many EMRs will skip from one placeholder to the next. 

Focus on Neck Pain – A Time-Saving Example (Type neckpain.history)

Our Neck Pain template, for example, helps you document the onset, symptoms, severity, and associated factors quickly:

  • Onset & Cause: Document when the pain started and its cause in seconds.
  • Symptom Description: Easily note whether the pain involves stiffness or radiates to the shoulder.
  • Aggravating/Alleviating Factors: Quickly select common factors like posture or physical therapy that affect the pain.
  • Associated ROS & Medical History: Capture related symptoms and relevant medical history, ensuring nothing is missed.

By following the template’s prompts, you’ll cover all bases, from pertinent negatives to associated social and family history, all within minutes.

Why It Matters

  • Save Time: Pre-populated sections and streamlined prompts help you document faster.
  • Enhance Care: Thorough, standardized history-taking leads to more accurate diagnoses and better patient outcomes.
  • Ease of Use: Access the templates you need by typing the patient's issue followed by ".history" - it's that simple!

Start using dotScribe’s history templates today to see how much time you can save while enhancing the quality of your patient care.