Templates/Prompts?
I don’t know if anyone has any experience in this area, but I figured its worth a try.
There is currently a committee at my facility to update the electronic templates MD’s are using to better capture data in I-10. They are approaching this task by service line hoping to assist the service lines in developing a few templates that will be able to be modified as needed. Of course CDI is to be involved in this process, as well as UR, Coding, Transcription, etc…
At a recent meeting there was some disagreement about whether it is compliant to ‘prompt’ MD’s for documentation that would potentially influence reimbursement. For example Ortho recently had a template built with the following prompts (among others):
Renal: Chronic renal failure (Stage)
Nutritional: Malnutrition (severity)/Obesity/Underweight/BMI
Immunologic:
Musculoskeletal: Osteoarthritis/Fracture (pathologic/osteoarthritic/traumatic)
Integumentary: Wounds/Decubiti (staging)
Neurologic: Hemiplegia (prior stroke?)
In the electronic environment, the MD would click on the conditions on the right in order to document them in the record. They also will Free text. If nothing is ‘clicked’ or entered into free test, the area is blank.
I have tried to find information from CMS on the compliance issues surrounding templates and I can’t find firm guidance. Mainly that templates can be employed and that prompts are ok too. However, I have not seen examples of ‘prompts’ available anywhere. I do see quite a lot of literature about how templates may be used to aid in achieving the documentation specificity required in I-10.
any and all help/feedback is appreciated!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
There is currently a committee at my facility to update the electronic templates MD’s are using to better capture data in I-10. They are approaching this task by service line hoping to assist the service lines in developing a few templates that will be able to be modified as needed. Of course CDI is to be involved in this process, as well as UR, Coding, Transcription, etc…
At a recent meeting there was some disagreement about whether it is compliant to ‘prompt’ MD’s for documentation that would potentially influence reimbursement. For example Ortho recently had a template built with the following prompts (among others):
Renal: Chronic renal failure (Stage)
Nutritional: Malnutrition (severity)/Obesity/Underweight/BMI
Immunologic:
Musculoskeletal: Osteoarthritis/Fracture (pathologic/osteoarthritic/traumatic)
Integumentary: Wounds/Decubiti (staging)
Neurologic: Hemiplegia (prior stroke?)
In the electronic environment, the MD would click on the conditions on the right in order to document them in the record. They also will Free text. If nothing is ‘clicked’ or entered into free test, the area is blank.
I have tried to find information from CMS on the compliance issues surrounding templates and I can’t find firm guidance. Mainly that templates can be employed and that prompts are ok too. However, I have not seen examples of ‘prompts’ available anywhere. I do see quite a lot of literature about how templates may be used to aid in achieving the documentation specificity required in I-10.
any and all help/feedback is appreciated!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
We have something like this at the VA in many of our templates. Our guidelines, which are not the same as CMS, indicate that "boilerplate text" is not allowed, but as long as they have to select the condition for it to appear in the health record you should be ok. If it automatically dropped in unless they de-selected it, then you would have a problem.
Hope this helps.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
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I can't remember what EMR system you have, but I recently viewed the outpatient diagnosis calculator from Epic (our EMR) that prompts physicians for specificity. If a doctor has a diagnosis of heart failure, a box pops up asking for acuity and type (diastolic/systolic), etc., but it does not prompt for diagnosis not already entered by the physician...that may be the difference.
We, too, will be working on templates for I-10 within the next month, but once again, it would be prompted by the physician entering a diagnosis and the template would help with specificity as well as clinical data to support the diagnosis.
Linda Haynes, RHIT, CCDS
Manager, Clinical Documentation
Legacy Health
lhaynes@lhs.org
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404