ED creates homegrown template system
Charts include space for handwritten notes
Unsatisfied with the quality and the cost of the template charting system they were using, emergency department personnel at the Medical College of Georgia and Children’s Medical Center in Augusta went their own way, creating a limited number of broad-based templates. (For an example of one of its templates, click here.) At the top of each template is a large box to allow for handwritten notes. "We allow enough room for people to put in what they need," says Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor of the department of emergency medicine and section chief for pediatric emergency medicine. "Then you go through your past, medical past, social and family histories, as well as your review of systems — all as check boxes," Mellick says.
The physical examination also is in check-box format, "but then there’s a fairly large section at the bottom that allows people to handwrite in additional elements. We find that this allows you to take one of these charts to the bedside and document as you’re talking to the patient," he adds.
Once complete, the charts are scanned. "So we do get an electronic format of the chart, and our coders then have the scanned chart for their review," Mellick says. "Just the actual process of having someone take the chart and look at it carefully before scanning it actually is a very important step — a funnel through which things slow down just enough that there’s someone carefully reviewing the 200 charts you do a day," he explains.
Mellick says any facility could take similar steps to create its own template system. "It’s just a matter of investing a little time and energy, researching what you need to have documented, and doing it," he says. "We found that finally when we did it, it was fairly painless, and it’s completely under our control. If we don’t like something, think we need to add something, or think we need to change the phraseology around, we just go in and do it, and then have another batch printed."
He notes that they probably will make some changes to their templates soon to reflect new documentation guidelines for teaching hospitals from the Centers for Medicare & Medicaid Services. "We’ve been very pleased with how we made the transition from paying a dollar a chart to paying pennies a chart, if less, for these forms," Mellick adds. "My bias is that a lot of these template charts are way too expensive. Someone’s making a lot of money, and if you just went to your business manager and said, Go into a room for two days and make up our own templates. . . .’"
Unsatisfied with the quality and the cost of the template charting system they were using, emergency department personnel at the Medical College of Georgia and Childrens Medical Center in Augusta went their own way, creating a limited number of broad-based templates.
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