Getting the full picture?
Some experts suggest that template charts fail to provide a full clinical picture of the patient’s condition. "The criticism of private attendings who are given template documentation rather than dictation is they cannot tell what is going on with the patient," says Graff. "There is definitely an issue with our non-emergency physician colleagues viewing this as a lower standard of documentation and less helpful to them when they have to follow up with the patient or admit the patient."
• 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 their 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 headache, 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 such as t-PA," 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 the Health Care Financing Administration (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 preaudit the record, so if you only reviewed nine systems, it alerts you."