Point/Counterpoint
ED managers: Don’t stop using template charting!
By David H. Moss, MD
President, Emergency Resources Group
Chief Developer, AAEM Templates
Milwaukee
As any craftsman knows, a tool is only as good as the task it’s used for. You wouldn’t want to build a house using only a hammer, and the same goes for documentation templates in the ED. Templates are the single most valuable tool for ED documentation, but like every tool, they have their limitations. It’s helpful to remember that documentation in the ED must fulfill seven different tasks:
- gathering, organizing and entering information;
- patient management;
- databasing and research;
- reimbursement;
- communication to other caregivers;
- medicolegal defense;
- continuous quality improvement (CQI).
Templates make data gathering and data entry a snap, by allowing real-time entry of information at the patient’s bedside in an organized and efficient fashion. Only templates — whether paper-based or digital — excel at this task. Dictation is always after the fact, while handwriting charts is a slow and tedious process that’s difficult to do at the patient’s bedside. Because templates, by their very nature, force the physician to be complete and organized, they also excel at providing a great format for databasing, research, medicolegal defense, and CQI.
Forget about dictation for patient management. It’s as useless as using a saw to drive a nail. The only choice is utilizing some kind of template system to communicate orders. Even the old-fashioned handwritten chart usually employs at least some rudimentary organization when it comes to patient management. But a well-designed template system excels when it comes to patient management, due to its high degree of structure and helpful prompting.
Templates are also the tool of choice when it comes to documentation for reimbursement purposes. Dictation’s weakness is that coders must wade through several pages of prose to determine levels of reimbursement, and even then, essential documentation is often missing.
Forget handwritten charts when it comes to reimbursement documentation. Either you’ll lose hundreds of thousands of dollars in lost charges due to incompleteness, difficulty abstracting coding information, or illegibility, or you face the risk of payer audits and penalties. You might as well tape a paper bull’s-eye on your chest, as you make such an easy and vulnerable target.
Templates, on the other hand, force completeness and allow for easy, reproducible scoring methods for coding and reimbursement purposes.
Communication with other caregivers is the one area where templates are an awkward tool. Nothing beats prose when it comes to communication, especially when attempting to convey complex thought processes. Template charts do a fine job at conveying standard, simple information, but there’s a learning curve when it comes to reading template charts. Dictation would be my tool of choice when it comes to communication.
But when one uses dictation as the stand-alone tool for other documentation tasks, its weaknesses become apparent. By the time you’ve dictated a record that’s adequate enough to be used for reimbursement and medicolegal purposes, you’ve got a two- to three-page document. No attending physician likes wading through several pages of verbose prose. And as many ED physicians can attest, creating that document feels like something akin to regurgitation. And with transcription costs running at $15 to $20 per hour, you’ve got an expensive proposition.
A more appropriate way to meet communication needs would be to use templates for most documentation purposes, but when you want to communicate something more complex to other caregivers, dictate a one- or two-paragraph summary. Facilities that choose this approach can cut transcription costs by 90% or more, and as important, you’ve got happier attendings.
Templates are a safety tool
If we’re completely honest, and don’t let our overblown egos get in the way, we’d also have to admit that the "prompting" function of templates provides us with a tremendous advantage. No matter how great a clinician you are, it’s easy to forget to ask for certain information, and it’s even easier to forget to document specific information. Templates, through their organized formatting and written prompts, can help fatigued clinicians avoid dangerous pitfalls.
Of course, templates aren’t perfect, and a poorly designed system is as dangerous or ineffective as any other defective tool. And like any tool, it’s only as good as the person wielding the tool. Sloppy, dishonest documentation can wreak havoc with the best designed template system. It’s all too easy to check off items that you never asked about or performed.
But template systems, whether paper or digitally based, still offer the best bang for the buck. They facilitate efficiency and completeness while allowing for real-time documentation at the patient’s bedside.
When physicians appear organized and thorough, and when they write down findings at the patient’s bedside, patients respond positively. Happier patients, greater efficiency, less fatigue, better reimbursement, enhanced quality of care — that’s a winning combination.
[Editor’s note: AAEM Templates is a product of AAEM Services, a division of the American Academy of Emergency Medicine (AAEM). AAEM is a Milwaukee-based not-for-profit association with the goal of improving the practice environment and quality of emergency medicine.
Emergency Resources Group is a consulting and management group specializing in emergency medicine. Contact Moss at 5770 North Shore Drive, Milwaukee, WI 53217. Telephone: (414) 962-6724. Fax: (414) 962-6798. E-mail: [email protected].]
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