diagnoses listed on templated paper progress note

lrubin

Our medical record is currently hybrid,with progress notes still in paper format.I was asked by the director of the orthopedic surgical service which had very high volume what common diagnoses could they list on a templated paper progress note.The surgeons want this progress note to be mostly check marks to make the progress note efficient for the user.Here are my questions and all feed back will be appreciated. 1.Has any one out there done this and in what format?2.Would you be willing to share with me and or have a phone call to discuss.3.For me a red flag relative to compliance goes off in my head- so would the consesus from the responders be ????
Thank you for all of your time
Lois Rubin
Manager Clinical Documetation SPHP
518-525-1081

kerryseekircher

Hi Lois-

I had a similar request a while back by our ortho MD's and we created a template in our EMR. I also had similar concerns that they were going to begin checking off acute blood loss anemia on every patient. For compliance purposes, we did several in-services with the groups and included the CMO. A great deal of education was done to stress the importance of documenting secondary conditions when clinically significant. For this reason, we incorporated this terminology in the template as well as common interventions for the secondary diagnoses. We also gave them the ability to free text additional documentation.

I'm copying the template below for you to see our example...., you may have far more/less secondary conditions; these are just a few of the common conditions here that we found were documented incorrectly or not at all.

I'm including my contact info if you have any questions.

Kerry



Kerry Seekircher, RN, BS, CCDS, CDIP

Documentation Specialist Supervisor

Northern Westchester Hospital

400 East Main Street

Mount Kisco, NY 10549

Email: kseekircher@nwhc.net

Phone: 914-666-1243

Fax: 914-666-1013

cmclose@saintfrancis.com

Great idea Kerry~ I like your template.



Claudine Hutchinson RN (CDI)

918-502-6603

evanspx@sutterhealth.org

Kerry - thank you for sharing. We had 'something like this' used in our=
paper record that we used to record final diagnoses and conditions in the =
ICU, progress notes...etc.

I will attach as a reference.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

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kerryseekircher

Paul-
These are great. Thank you for sharing.
Just out of curiosity, were your physicians mandated to use these forms, or were they able to pick and choose? If mandated, I would imagine you have great capture of some of the most common queries!
In our case, our CMO added the template as an option for their use. Most of the surgeons after a while got so used to the terms, that they began independently adding them into their regular notes and bypassing the template.
Thanks,
Kerry

evanspx@sutterhealth.org

These were never mandated, but were uses sometimes, by our staff. Yes: Use of these forms will decrease need for queries.

Paul

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

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vsimonet1

Hi Paul,
Thank you very much for sharing this.

Sincerely,

Veasna Simonet, MHA, CPC
HCC Coding Supervisor, Coding Initiatives
Caloptima, 505 City Parkway West, Orange, Ca 92868
Phone: (714) 347-5792; Fax (714) 954-2312
Email: vsimonet@caloptima.org
Web: www.caloptima.org