Templates save time, money on documentation
System has cut dictation time in half
Coding from incomplete emergency department (ED) records can be a struggle. Some health information management professionals, though, have found relief with template charting systems. They say the systems cut documentation time, eliminate transcription costs, and ensure accurate coding.
Template charting systems are a compilation of standardized forms used for ED documentation. The forms have a complete section for present illness, past history, related procedures, and final diagnosis. Physicians check boxes and diagrams according to their patient examinations.
Although nonemergency department physicians sometimes find this documentation less helpful and less flexible when they have to follow up or admit a patient, many ED physicians like it. Many physicians say the forms are more readable, meet Health Care Financing Administration (HCFA) documentation requirements, and are faster since much of the charting can be done at the bedside while interviewing the patient.
Here are some potential benefits of template documentation systems according to various hospital administrators and physicians Hospital Payment & Information Management spoke to:
• Reduced costs.
The costs are between those of traditional dictation and voice-activated dictation, users say.
EDs that switch to template charting from dictated transcription can save considerable amounts. "The [system] has cut our ED dictation by 50% and has improved coding productivity for E/M coding since this is done in our HIM department," says Judy Terry, RHIA, director of health information management at Madison Memorial Hospital in Rexburg, ID.
"We saved our hospital between $125,000 and $150,000 in transcription fees," reports Wayne Christiansen, DO, FACEP, an ED physician at Charlton Medical Center in Fall River, MA.
• Quicker documentation. Because there may be hundreds of different templates, a well-designed form enables clinicians to learn quickly where specific sections are. "Once they have learned that, when they pick up a template form, they instantly know where to look for a particular item," explains Randall B. Case, MD, FACEP, director of emergency medicine systems for Cerner Corp. Cerner is a supplier of clinical information systems based in Kansas City, MO. "That isn’t the case when you are using a free-form paper chart." (See list of vendors, p. 22.)
• More accurate coding. The charts make it easier for coders to justify forms of treatment, says Linda Vires, RHIA, assistant director of the health information department at Valley View Regional Hospital, in Ada, OK.
For example, a physician using a free-form chart may have written, "Patient fell and fractured arm. EKG given." The coders would not know the justification for the EKG.
"[With template documentation], physicians have to check off the history," she says. By reading the history that the physician has also listed on the back of the form, coders find out that the patient has a pacemaker and the physician did an EKG to check its function. "I think it’s a more complete record," Vires says.
ED physicians can also use the information on the templates to qualify for various levels of care. "[The information] serves as a mental cue to remind you to ask for certain elements that are necessary for the patient history or look for certain things on the exam," Christiansen says. "That ensures you qualify for whatever level of care is indicated for the problem."
For example, the diagnosis for a patient with a cold may seem straightforward, but specific questions may reveal additional problems that aren’t readily apparent. "For example, you may discover the patient has a sore throat, a rash, or headaches," he says. "When you start doing the physical exam, you find you have moved from just one single body system to several." The diagnosis is substantiated by a more extensive history and physical, more time is involved, and it may qualify for a higher level, he explains.
• Thorough documentation of rechecks. At Charlton, the ED group was failing to document rechecks on patients, resulting in lost revenue. "Physicians are notorious for not documenting those rechecks. Physicians were relying on nursing notes to reflect the changes in the patient, but the physician needs to do so also," says Christiansen.
For example, physicians may not document the time spent with a very sick patient with pulmonary edema who requires a lot of time at the bedside and repeated exams. "The template prompts you to write down the time and what the patient looks like during each recheck, and [it] has a specific code for that," he says.
The form improved the group’s reimbursement in terms of category justification, including rechecks. "Previously, doctors would look at patients every half-hour without thinking of reimbursement for that, but the form reminds them to document everything," he says.
• An immediately available record. If a patient returns again in a few hours for the same problem, the information about the previous visit is accessible, says Christiansen. "You don’t have to wait for it to be transcribed, and the record reflects lab work, which you may not want to repeat again," he explains. "Or the physical exam may have changed since the patient was in. If a patient comes in for the second time with abdominal pain, which is now localized to one area, the chart is right there for you."
• More consistent care. Template forms allow all physicians in an ED group to have a uniform approach during assessment and physical exam. "For example, if a patient presents with a head-ache, the form tells you to ask about carbon monoxide exposure," notes Christiansen. "That’s not something everyone would think to ask, but this way the question is posed."
An ED group can modify a template to produce a consistent standard of care. "The templates are very well-suited to developing a group consensus for complex high-cost treatments," says Case.
• Information that can be shared easily. With a computerized template documentation system, data can be shared in real time. "This is very significant in the ED, because the information can be shared with the floors instantly," says Case.
• Reduced liability. Because templates encourage complete documentation, you have better capability to defend yourself against allegations of malpractice, says Case.
• Less ambiguity. Templates are designed for a patient’s specific chief complaint. "Digitalized human photographs on most of the charts take away ambiguity of the actual location of injury/ pain," notes Jeffrey Oyler, MD, president and chief executive officer of the Atlanta-based Poseidon Group, which developed a template system.
• Compliance with documentation requirements from HCFA. Many ED groups have switched to template documentation for this reason alone, notes Case. "HCFA has become more and more specific in recent years as to what has to be documented for each level of service," he says. "As a result, the care provider not only has to think about what the patient needs, but also be concerned with what they need to document."
To constitute a valid Level 5 charge, 10 out of 14 body systems must be covered in the physician’s review of systems. "If a complex cardiac patient in shock with arrhythmia is being admitted to the cardiac care unit with an acute heart attack, the physician can’t just focus on the heart and lungs, because HCFA also requires a review of other systems, such as neurologic, [gastrointestinal], and psychiatric," says Case. "If the clinician fails to do so, the charge will be reduced."
If an invalid charge is found repeatedly, the hospital also could be charged with fraud and abuse, he warns. "You can be cited if you are billing for Level 5 services when you didn’t document them. Computerized template systems can pre-audit the record, so if you only reviewed nine systems, it alerts you."
Selected Template Vendor List
Here is a partial listing of vendors that offer template documentation systems:
- The Navigator: a template documentation system designed to meet Medicare requirements. Contact: The Poseidon Group, 79 Poplar St., Suite C, Atlanta, GA 30303. Telephone: (404) 261-0401. Fax: (404) 524-7789. E-mail: CscottG8R@ aol.com. Web: www.poseidongroup.com.
- The T-System: a template charting system with more than 50 documentation tools, including adult and pediatric templates. Contact: Emergency Services Consultants, 4020 McEwen Drive, Suite 281, Dallas, TX 75244-5091. Telephone: (972) 503-8899. Fax: (972) 503-8898. Web site: www. tsystem.com.
- PowerNet: a structured documentation module within the FirstNet Emergency Department Information System. Contact: Cerner Corp., Enterprise Marketing Specialist, 2800 Rockcreek Parkway, Kansas City, MO 64117. Telephone: (816) 201-3460. Fax: (816) 201-9460. Web site: www.cerner.com.
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