As electronic medical records have evolved, so have physician documentation methods. Based on our observations in recent years, we have noticed that as organizations migrated away from paper templates, many only developed two or three generic electronic documentation templates for physicians to use (Adult Template, Pediatric Template, Trauma Template).
While not ideal for every patient encounter, this two- or three-template approach has sufficed for some organizations because the templates allow physicians to jump into white space and make notes about a patient. However, while free text and dictation do allow the provider to document a better narrative, they don’t help capture certain pieces of structured discreet data that need to be documented in an easy fashion. Because discreet data has become important for reporting and quality measures, most physician documentation templates allow a healthy mix of both dictation and structured data fields in the chart documentation.
Given the ever-evolving target of exactly which quality measures to capture and report to CMS, relying on providers to remain current on those measures and ensuring that their records appears to be a losing proposition. Thus, leaving these fields as optional in the medical record introduces a lot of back and forth between quality, billing, and coding for the physician just to close one patient encounter.
In response, we have noticed that many organizations mandate certain fields on their generic templates, but because the measures can vary based on the condition, you might be requiring something that has no relevance to the current patient encounter. This approach can waste physician time completing unnecessary mandatory fields, and it can increase their frustration with electronic documentation altogether.
The Benefits of Chief Complaint-Specific Templates
Developing a library of chief complaint-specific templates can be a daunting task for many organizations and clinical analysts. When you consider the amount of information that needs to be built into the EHR system and the intimate understanding a clinical analyst must have of a physician’s workflow and clinical practice, it is easy to realize why many organizations simply resort to a smaller set of templates when under a time crunch. However, let’s consider some of the benefits that a chief complaint-specific approach with ED documentation can provide.
Workflow: It seems intuitive that more closely mirroring the clinical content in the structured templates to the presenting patient’s complaint would facilitate provider workflow and documentation. Moreover, by adopting a chief complaint-specific strategy, you can also more closely define the “Normals” that are pre-programmed into the Review of Systems and Physical Exam sections. For example:
- When a provider documents “All Normal” for a neck exam on an MVA Template, they might hope to see “Atraumatic, Non-Tender, No Tracheal Deviation” pre-programmed into the template.
- Alternatively, when a provider documents “All Normal” in a neck exam on a Fever Template, they might hope to see “Supple, No Meningismus, Full Range of Motion, and No Adenopathy” selected for their pre-programmed “Normals.”
Providing this functionality can save physicians many clicks throughout the course of their shifts and will help facilitate their workflow.
Mandatory Fields are Relevant: Delivering chief complaint-specific templates to the physicians can help reduce their frustration with having to document completely irrelevant fields. In addition to the quality metrics required for reporting, TSG has identified elements in the HPI and PE that have often been associated with dx-related adverse events. We like to draw attention to those clinical elements in the documentation template, and since we are serving up chief complaint-specific templates (stratified based on age and sex), we get less pushback from physicians when we request that they address Onset and Movement of Pain in a Chest Pain Over 40 Template.
Patient Safety & Stronger Documentation: Building off the previous point, implementing a chief complaint-specific strategy gives physicians a more tailored H&P for the patient presentation. For example, a 0-2 y/o Abdominal Pain Template will look different than a Female Over 40 Abdominal Pain Template. In the 0-2 y/o Template, we are going to serve up content in the History that will help the physician focus on the possibility of intussusception, malrotation and hypertrophic pyloric stenosis. Alternatively, in the Adult Abdominal Pain Template, they may want to consider Appendicitis, AAA, Ectopic Pregnancy, and other conditions more often associated with that patient demographic. Providing this specific clinical content helps physicians consider these high-risk (too often missed) conditions and more thoroughly document those patient visits.
The Challenges
The lack of chief complaint-specific template adoption can be attributed to the massive resources required to both build and manage such content.
Even if an organization has the manpower available, are those individuals qualified to develop the content in a manner aligned with the physician workflow? Consultants might offer up the time (and bill accordingly) for template creation, but they don’t have the intimate understanding of a physician’s workflow, clinical practice, and decision-making process. Some organizations engage nurses to build physician templates, but this is also a mismatch of interest. Nurses, as practicing clinicians, have a different role and perspective on the care team; therefore, they might not have the intimate appreciation for why physicians want a template in a certain manner. Ideally, physicians would build physician documentation templates. And herein lies the problem – do organizations have the physician resources to allocate toward this development? To pull them away from an already overloaded patient schedule?
Another barrier for organizations is the ongoing complexity of managing more than a handful of templates. Quality measures are ever-evolving. New evidence-based medicine is released daily. Making updates to a large content library to stay current also requires an allocation of immense resources.
Approaching Documentation with a Patient Safety Focus
Recognizing both these benefits and challenges, one of the largest health systems in the country, and consequently the largest MEDITECH EMR user, approached TSG to develop chief complaint-specific templates for MEDITECH physician documentation.
Templates were created by our team of clinical and technical champions and were then reviewed by a Physician Advisory Group of 20 board certified physicians. Because dictation is still one of the most time-efficient ways to document, the templates developed allowed for both dictation and the selection of discreet data. However, templates only required certain discreet data based on the presenting chief complaint. What’s more, the templates aid in bedside clinical decision support, notifying physicians of abnormalities in vital signs and recommending documentation of certain risk factors, all in the quest toward better patient care and more complete, defensible physician documentation.
Because of this collaboration, these chief complaint-specific templates – vetted by physicians for physician use – are available to organizations across the country without the initial development investment or internal resource requirement.
TSG also shoulders the burden of updating the system. We manage the templates and deploy updates to evolve with industry practice changes so your internal team can focus on your own initiatives.
Now implemented in more than 170 facilities, our chief complaint-specific templates are helping organizations improve physician satisfaction and reducing the likelihood of diagnostic error.
