ER/Builder Best Practices: Custom Templates, Reporting, and TrainingEmergency departments (EDs) face constant pressure to deliver fast, accurate care while maintaining clear documentation and meeting regulatory requirements. ER/Builder, a clinical documentation and workflow tool designed for emergency medicine, can significantly reduce documentation burden and improve patient throughput when implemented and used effectively. This article outlines best practices for three core areas—custom templates, reporting, and training—to help ED leaders, clinicians, and informatics teams get the most value from ER/Builder.
Understanding ER/Builder’s Role in the ED
ER/Builder centralizes documentation, allows structured data capture, and supports customized workflows tailored to emergency medicine. Its strength lies in enabling clinicians to document efficiently without sacrificing the clinical detail required for billing, quality metrics, and follow-up care. Getting ER/Builder to work smoothly requires configuring it to your department’s clinical workflows, establishing reporting processes that drive improvement, and training staff so adoption is high and consistent.
Custom Templates: Design Principles and Examples
Custom templates are the backbone of efficient documentation. Well-designed templates reduce clicks, standardize data capture, and ensure required elements are recorded.
Key design principles:
- Clinician-centered design: Build templates around how clinicians think and work—presenting the most commonly used fields first and minimizing unnecessary fields.
- Simplicity and flexibility: Keep templates concise but allow quick expansion for complex cases via conditional logic or “more details” sections.
- Consistency across roles: Ensure templates for physicians, PAs/NPs, nurses, and scribes align so data can be aggregated and compared.
- Regulatory and billing alignment: Include required elements for CMS, local regulations, and payer documentation to avoid denials and compliance issues.
- Leverage defaults and macros: Use evidence-based defaults for order sets, medications, and discharge instructions to speed documentation while allowing easy adjustment.
Template examples and features:
- Chief complaint–based templates (e.g., chest pain, abdominal pain, syncope) that pre-populate relevant review of systems, exam checklists, and order bundles.
- Procedure templates for laceration repair, joint reduction, and wound care with stepwise fields for consent, anesthesia, technique, and aftercare.
- Observation and disposition templates tailored to common ED pathways (e.g., short-stay chest pain observation) with discrete fields for monitoring intervals and criteria.
- Nursing triage templates that capture acuity, vital sign trends, fall risk, and initial screening tests efficiently.
- Scribe-friendly views that streamline note-writing by collapsing rarely-used sections and exposing high-yield content.
Implementation tips:
- Start with high-volume complaints and build iteratively—pilot five templates, refine with clinician feedback, then expand.
- Use analytics (see Reporting section) to identify bottlenecks and template sections that trigger extra edits or time.
- Establish a governance process (small multidisciplinary committee) to approve changes so templates remain consistent and clinically sound.
- Version control templates and keep a changelog so teams can revert or audit modifications.
Reporting: Metrics That Matter and How to Use Them
Robust reporting turns documentation into actionable insights. ER/Builder’s discrete data capture enables measurement of clinical operations, quality, compliance, and education needs.
High-value reporting categories:
- Operational metrics:
- Door-to-provider time, triage-to-room, length of stay (LOS) by chief complaint, and left without being seen (LWBS).
- Time-stamped events from templates (triage, first MD contact, orders placed, disposition decision).
- Documentation quality:
- Rates of completed templates, missing key fields (e.g., allergies, consent signatures), and free-text overrides.
- Time-to-complete note and after-visit coding accuracy indicators.
- Clinical quality and safety:
- Compliance with sepsis bundles, stroke and MI pathways, and antibiotic stewardship measures captured via discrete fields.
- Procedure complication rates and follow-up adherence.
- Billing and coding:
- E/M level distributions, modifier usage, and audit flags where documentation elements are inconsistent with billed levels.
Best practices for reporting:
- Align reports with departmental goals (e.g., reduce LOS by 10% or improve sepsis bundle compliance to 90%).
- Build dashboards with real-time operational indicators for clinicians and managers and deeper scheduled reports for leadership.
- Use drill-down capability: a high-level metric should link to patient-level data so teams can identify specific cases for learning or correction.
- Automate alerts where appropriate (e.g., when a sepsis bundle has incomplete fields after 3 hours).
- Validate discrete fields and mapping to ensure reports represent clinical reality—periodically audit samples against chart text.
Examples of actionable uses:
- Identify which complaint templates correlate with longer documentation times and simplify them.
- Track which clinicians or shifts have higher rates of incomplete fields, then target coaching or template tweaks.
- Monitor practice patterns (e.g., imaging usage for minor head injury) and design decision-support prompts where overuse is detected.
Training: Strategy, Content, and Reinforcement
Even the best templates and reports fail without consistent user proficiency. A layered training approach maximizes uptake and reduces variability.
Training components:
- Role-based curriculum: separate tracks for physicians, advanced practice providers, nurses, and scribes focusing on their workflow and templates.
- Hands-on, scenario-based sessions: simulate common ED cases using the templates and include both routine and edge-case scenarios.
- Bite-sized microlearning: quick videos (2–5 minutes) showing new template features or shortcuts accessible in the EHR.
- Superuser/peer champions: identify power users on each shift who can provide point-of-care help and collect feedback.
- Documentation standards guide: concise reference of required fields, common pitfalls, and examples of high-quality notes.
Onboarding and ongoing education:
- New hires: structured onboarding that includes ER/Builder practice cases before clinical shifts.
- Continuous refreshers: monthly briefings for new features, common documentation errors, and performance highlights.
- Targeted remediation: use reporting to identify clinicians with documentation gaps and offer one-on-one coaching sessions.
Measuring training effectiveness:
- Track time-to-competency (e.g., number of shifts until consistent template completion).
- Monitor documentation error rates, completion times, and template utilization before and after training interventions.
- Survey clinicians for perceived usability and then correlate with objective metrics.
Governance, Maintenance, and Change Management
Long-term success requires a formal process to manage changes, balance clinician needs, and ensure system stability.
Governance structure:
- Multidisciplinary council including ED physicians, nursing leadership, informatics, coding/billing, and IT.
- Regular meetings (monthly or biweekly during heavy change periods) to review requests, prioritize, and approve template changes.
Change management best practices:
- Test changes in a sandbox environment and pilot with a small group before wide release.
- Communicate changes clearly: what changed, why, and where to find training resources.
- Maintain a rollback plan and versioned templates for quick reversal if unintended consequences appear.
- Use frequent short feedback loops after changes to capture issues and iterate rapidly.
Technical maintenance:
- Ensure discrete fields map correctly to reporting and coding systems; test after upgrades.
- Monitor system performance—template complexity can impact load times on slower devices.
- Coordinate with IT for regular backups and to manage integrations (lab, radiology, ADT feeds).
Common Pitfalls and How to Avoid Them
- Overly complex templates: fix by simplifying and using conditional logic to show advanced fields only when needed.
- Lack of clinician buy-in: involve frontline clinicians early, pilot changes, and show data linking template improvements to efficiency gains.
- Ignoring reporting validation: periodically audit reports against chart text to ensure accuracy.
- One-off customizations without governance: these create maintenance burdens—channel requests through the governance council.
Roadmap: Phased Implementation Example
Phase 1 — Foundation (Months 0–3)
- Implement core templates for top 5 chief complaints.
- Create real-time dashboard for door-to-provider and LOS.
- Train core clinicians and designate superusers.
Phase 2 — Expansion (Months 4–9)
- Add procedure and disposition templates.
- Build quality reports for sepsis, stroke, and MI pathways.
- Roll out microlearning library and monthly refresher sessions.
Phase 3 — Optimization (Months 10–18)
- Use analytics to refine templates, reduce clicks, and automate alerts.
- Conduct targeted remediation for outliers.
- Formalize governance and continuous improvement cycles.
Conclusion
ER/Builder can substantially improve emergency department efficiency, documentation quality, and compliance when configured thoughtfully and supported with targeted reporting and sustained training. Focus on clinician-centered template design, actionable reporting tied to goals, and role-based training reinforced by governance. Incremental changes, strong feedback loops, and data-driven refinements turn ER/Builder from a documentation tool into a lever for measurable operational and clinical improvement.
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