Purpose: To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process.Methods: A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a ؊2 to ؉ 2 Likert scale. Means and standard deviations are reported.Results: A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was $150 and for the template system it was $163-a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method.Conclusions: The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.

CasePatient X is a 55-year-old man, 72 inches tall, weighing 86 kg, status post motor vehicle accident with multisystem trauma. The patient is currently receiving sedation, pain control, and maintenance IV fluids; he received 3 liters of NS bolus, 2 units of FFP, and 2 units of PRBCs on admission. On admission, labs included CRP -2.1mg/dL, Alb -4.5 gm/dL and transthyretin (TTR, prealbumin) -17mg/dL. Labs on day three showed that the CRP was 37 mg/dL, Alb 1.2 gm/dL, and transthyretin 10 mg/dL. In an overall assessment of the patient, the clinician states that based on the most recent labs, enteral or parenteral nutrition needs to be started due to malnutrition as indicated by his low albumin. DisCussion Malnutrition in the iCuMalnutrition is very common in critically ill patients, and its development is a function of the patients' preexisting nutritional status and severity of illness (degree of hypermetabolism). The characteristics of ICU patients have changed during the last decade; they now tend to be older and their medical disorders more complex with frequent comorbidity. These factors may contribute to malnutrition in the ICU. The combination of stress and undernutrition is associated with negative energy balances and the loss of lean body mass 1 . Critically ill patients often have a history of decreased food intake from anorexia, gastrointestinal symptoms, depression, anxiety, and other medical and surgical factors on presentation. Their food intake may have also been restricted for diagnostic or therapeutic procedures during hospital stay, and they may have nutrient loss from diarrhea, vomiting, polyuria, wounds, drainage tubes, and renal replacement therapy 2,3 .The major physiologic change

The UT Southwestern Virtual Wound Care Clinic provides care to disabled institutional residents in an urban setting. The program offers flexible financial mechanisms for residents of the facility to access specialty care. Telemedicine improves quality-of-life and reduces costs by minimizing patient transportation. The exchange of clinical knowledge benefits both parties.

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