The pros and cons of template charting: What you need to know
How to figure out what’s best for your facility
Challenged by increasingly stringent documentation requirements, many emergency departments are turning to template charting systems as a way to cut documentation time, eliminate transcript costs, and ensure accurate coding. But systems vary widely in terms of cost, specificity, and other factors. How do you know what’s best for your facility? To be sure, template charting has its critics — primarily physicians, who may view any type of standardized documentation tool as a form of cookbook medicine.
"In the 50% to 60% of departments that don’t use any kind of templated documentation, you find that you have physicians who, for one reason or another, say, You know, we’re documenting a certain way; we’re comfortable with that way; we don’t want to change,’" says David H. Moss, MD, president of Emergency Resources Group and chief developer with AAEM Templates in Milwaukee.
"Some physicians just don’t want to be shepherded down a particular path. So when you say to an entire department, We’re going to be adopting template use,’ there’s invariably going to be some physicians in some departments who say, No way am I going to do what everybody else is doing,’" he adds.
Nevertheless, in light of tougher documentation requirements from the Centers for Medicare & Medicaid Services, increasing numbers of physicians are going along with the move toward template documentation, according to Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor, of the department of emergency medicine and section chief of pediatric emergency medicine, at the Medical College of Georgia in Augusta. "I think you’re obligated to, for ease of documentation and for coding purposes of capturing all of the information, as well as making it easier for your coders to identify when something’s missing," he says.
Mellick says it’s "almost unfair" to make coders work through a nonstructured dictation or a scribbled handwritten chart to find the appropriate documentation elements. Such practices also may increase the risk of coding errors. "Or the coders simply will not be able to find things and, when rushed, will simply down-code so there won’t be accusations of fraud," he explains.
Patrice Spath, RHIT, a health care information consultant with Brown-Spath & Associates in Forest Grove, OR, adds that, "from a patient safety standpoint and from a quality of care standpoint, any time you can make it easier for people to do the right thing, then it adds value. "Any time you can reduce variation in a process, it adds value. So a template would be no different from a clinical pathway or an algorithm or anything else that essentially puts reminders in front of peoples’ faces about what they ought to do," she says.
Currently, Moss says, EDs have five choices when it comes to documentation:
- handwritten charts;
- dictated charts;
- voice-activated charts;
- paper-based template systems;
- computerized systems.
Of those choices, paper-based and computerized template systems come out on top because only they prospectively help to improve the quality of care because of their prompting mechanisms. For example, when a patient presents to the ED with chest pain, "the template can prompt you to address the patient’s risk factors for myocardial infarction, or for pulmonary embolus," Moss says. "Handwritten charts and dictated charts fail to do that totally, because they’re done after the fact."
"[Templates] just remind people to think about what they should be thinking about," Spath adds. And that goes beyond quality of care to legal and regulatory issues as well. "From an EMTALA [Emergency Medical Treatment and Active Labor Act] standpoint, making sure that certain things get documented in a consistent fashion is valuable also. It comes down to making it easier for people to do the right thing," she explains.
Another way templates shine is by allowing efficient, real-time entry of documentation, Moss says. "Handwritten charts allow real-time documentation of information, but they’re very inefficient. Dictation fails to provide real-time entry of information. You always do it after the fact."
Documentation should complete 7 tasks
According to Moss, documentation should fulfill seven different tasks:
- gathering, organizing, and entering information;
- patient management;
- databasing and research;
- reimbursement;
- communication to other caregivers;
- medicolegal defense;
- continuous quality improvement.
"I think ED templates do the single best job of any potential documentation solution in fulfilling most of those tasks, and doing it in the most efficient and thorough way possible," he says. Even so, Moss cautions against using one approach to the exclusion of all others. In reality, the best approach might be a combination system.
"Where templates have a weakness is in conveying information to other caregivers," he says. "We’re basically a society of storytellers, and that’s where a dictated chart excels, because it follows a narrative format. You can abstract information and get a gestalt of the patient more easily with dictated charts." But dictated charts have their own weakness — most notably, they’re expensive and time-consuming.
"My suggestion is that the ideal approach should be to use templates for the majority of information, but use dictation to convey complex information, where you just want to summarize what’s going on with the patient because you’re going to use that for communication purposes," Moss says.
"If you had an emergency department where you utilized templates and you allow supplemental dictation, I think you’ll find that you’ll be using dictation probably 10% of the level you were using it before. But that 10% is important. Those are the complex cases, the cases where you really want to convey important information. And I would give physicians that opportunity," he explains.
Of course, not all template systems are created equal, and some may be overly burdensome in their requirements. Mellick criticizes systems that "have a chart for every possible patient complaint. "You ought to have a template that’s broad and general and covers enough categories, and not get into chief-complaint-specific templates," he says. The problem, Mellick says, is that a physician has to choose, up front, from as many as 50 potential templates, and that initial choice may "take you down a pathway that is not appropriate for the patient. For example, someone may come in with leg pain and really turn out to have thrombophlebitis."
"Oftentimes, a particular chart for the particular complaint, like leg pain, really is set up for a lower level of documentation, as well as a lower level of coding," he adds. Mellick adds that, all too frequently, what seems to be a simple complaint that merits a low coding level turns out to be a critical care situation. Mellick and his colleagues at the Medical College of Georgia have addressed this problem by creating templates of their own.
Moss acknowledges that having a small number of more generalized templates makes it easier to select the correct template on the front end. "But then it’s not very helpful, frankly. And if you want a template that will prompt you to address the patient’s problems and efficiently document information, you have to tailor it toward the presenting complaint," he says. According to Moss, 90% of the time, it’s easy to select the correct template. "And somewhere between 5% and 10% of the time, patients complain with multiple problems, and you have to prioritize, which we do clinically anyway."
He acknowledges that there are some patients whose presentation evolves as they progress through the ED. "So there has to be some flexibility. And that’s an inherent weakness of templates, but frankly, you have the same problem with a handwritten chart and a computerized system also." Moss adds that he regards this a minor weakness. "It just doesn’t come up all that often."
Mellick also notes that the cost of using commercial charts can be exorbitant. His facility went that route for about a year, paying $1 per chart for about 60,000 patients. "We said, Why are we paying so much money for charts that don’t work for us?’ It did help in our coding, but it also hurt us in our coding, because it was not uncommon to have charts that were set up to be a level 1, 2, or 3, but the complaint was a more critical problem," he points out. Moss says that handwritten charts probably have the cheapest out-of-pocket price tag. "The problem is, you’re really going to lose on reimbursement by relying on handwritten charts, and you’re also going to have medical-legal costs."
Dictated charts probably are the most expensive. "If you’re using an agency outside the hospital, you’re probably paying between $5 and $6 a patient. In the hospital, it’s actually probably more expensive," he says. Meanwhile, costs for computerized systems are "all over the place." With templated systems, "you’re looking at anywhere from 50 cents a patient to a couple of dollars. So I think, generally, they’re pretty reasonable," Moss explains.
Challenged by increasingly stringent documentation requirements, many emergency departments are turning to template charting systems as a way to cut documentation time, eliminate transcript costs, and ensure accurate coding.
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