Point/Counterpoint
It’s time to give up costly template charts
By Larry B. Mellick, MS, MD, FAAP, FACEP
Chair and Professor
Department of Emergency Medicine
Section Chief, Pediatric Emergency Medicine
Medical College of Georgia, Augusta
While template charting has had a positive impact on our practices and reimbursements, it is my opinion that it is now time to reassess what we have learned recently.
Current template charting systems are best described as extensive collections of individual chart templates (50 or more), with each addressing one of many possible patient chief complaints. Prescription writing and discharge instructions often are part of the commercial template chart package.
The charts themselves are segmented nicely into various historical sections, as well as sections for documenting the examination and laboratory results. Sections to allow maximal coding and billing also are included. These charts are typically one or two pages (front and back) in length. They may be preprinted or may be computer generated at the point of service. The price of commercial chart systems is typically at least a dollar per chart, roughly correlating in dollars to the number of ED patients seen per year.
In reality, the concept of a chart template is neither unique nor new. ED physicians have been making various versions of template charts for years. With the advent of Medicare documentation requirements, the pressure to facilitate documentation increased.
Are template charts a clear step forward? In my opinion, they have made positive contributions to the current practice of emergency medicine. Even though much of the required information has limited value to the care of our patients, we must "play the game." The application of chart templates to the patient care process appears to improve revenues, as more complete documentation is consistently required.1
Coding is facilitated, as screening for incomplete charts can be accomplished with a simple glance at the chart. Template charts are more efficient, and bedside charting is facilitated. These same charts may provide increased benefit in risk management. The health care provider is prompted by their structured layout, thereby lessening the risk of omitted information. So, what areas are not steps forward?
• There are simply too many chart templates. There is no need to have a chart for every possible patient complaint. The charts often are too specific for the patients presenting with vague or multiple complaints. It is not uncommon to find yourself using a chart that does not match the acuity of the patient. "Leg pain" can be a deep venous thrombosis leading to admission or a minor pulled muscle treated with ibuprofin.
One’s option when inadvertently encountering a higher acuity patient, is to start over with another chart or to expand documentation onto the margins of the page. Secondly, the charts frequently are criticized because they do not "tell a story." Consequently, the best templates will compromise and allow adequate space for nontemplate or open documentation.
• The process of using the charts can be inefficient. The time required to select and print the "correct" chart for each patient can add to inefficiency. Simply picking up a preprinted chart formatted to handle multiple chief complaints is the most efficient format.
• The exorbitant cost of the charts is prohibitive. One must seriously question whether there is a good match between value gained and price demanded.
• There are mechanical-operational inefficiencies that exist with current template systems. The decision process for choosing the correct template for patient chief complaint is not always so simple. Often it is more efficient to wait and talk to the patient before picking a template. Consequently, one loses the efficiency of having a template immediately at the bedside. While the electronic prescription writing and discharge instructions (which often are part of the commercial systems) may be of some value, they are not necessarily more efficient.
• Unique patient histories must be forced into overly structured template charts. There is the risk of mentally "railroading" the data intake process or following a history trail that would not have occurred naturally.
• The printing of the paper forms is a problem. Even the fastest printers are too slow. Simply snatching up a standard (general) template form from a stack of forms and walking into the room is much more efficient.
In summary, it is my opinion that we don’t need 50 different chief complaints to choose from. It is possible to function just as efficiently with only a limited number of templates. (See Emergency and Express Care Services Record.) While the process of creating your own templates may seem like one more unwanted administrative headache, consider the current price of commercial systems. The process can be relatively easy if you don’t buy into the theory that you need a different chart for every chief complaint out there.
Finally, my intent is not to dismiss the important contributions made by those who have introduced and marketed the template chart concept. Nevertheless, as our specialty and practices mature, it makes sense to carefully evaluate our current approaches to template charting.
[Editor’s note: Contact Mellick at Department of Emergency Medicine, Medical College of Georgia, 1120 15th St., AF 2036, Augusta, GA 30912-2800. Telephone: (706) 721-6619. Fax: (706) 721-7718. E-mail: [email protected].]
Reference
1. Marill KA, Gauharou ES, Nelson BK, Peterson MA, Curtis RL, Gonzalez MR: Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med May 1999; 33:500-509.
Resource
Free electronic copies of template forms are available from the Medical College of Georgia. To obtain copies, contact:
• Howie Neuman, Administrative Specialist, Medical College of Georgia, Emergency & Express Care Services, 1120 15th St., AF-2037, Augusta, GA 30912-2800. Telephone: (706) 721-7942. Fax: (706) 721-7718. E-mail: [email protected].
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