American College of Physicians: Internal Medicine — Doctors for Adults ®

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Building better patient notes by using templates

From the October 1998 ACP-ASIM Observer, copyright 1998 by the American College of Physicians-American Society of Internal Medicine.

Editor's note: In the June issue of ACP-ASIM Observer, the author talked about the importance of HCFA's evaluation and management (E/M) guidelines ("Why you still need to pay attention to E/M guidelines,"). This month, he describes how templates can help document patient visits.

By David L. Blecker, FACP

During recent hospital rounds, one of our concerned nurses asked me to interpret the following patient note:

"Ht: L1. . . . . . . . L2
Lgs: Cr
Stable R"

I suggested several very different possibilities: (1) A patient with hypertension had developed bradycardia and a very loud S1 and S2 (hence the substitution of L for S), with clear lungs and a stable condition; (2) heat was being applied to a patient with a widely herniated L1-L2 disc and pain radiating down the L[e]gs, with a stable creatinine; (3) the patient had received a heart transplant placed between L1 and L2 with the lungs and Cor (heart) being stable.

Unfortunately, none of these interpretations applied to the patient. I am now considered a failure among the nursing staff. After all, I must be out of the mainstream of medicine if I can't understand a simple progress note!

Although this note may appear unusually vague, it is typical of many that I used to find on my charts and still do on those of other busy physicians. We fear that we will spend too much time writing, taking precious time from patient care. I have often spent 10 minutes examining a patient and less than one minute writing about the encounter. As a result, charts often do not reflect the work done. In addition, incomplete patient notes expose physicians to malpractice claims and frustrate reviewers and other caregivers. Abbreviations or other shortcuts may not save any time: The physician may later be required to interpret the note, and may spend extra time explaining it. For example, would the author of the note above recall whether "Ht" refers to hypertension, heart, heat or height?

Templated progress notes can save time by allowing physicians to accurately document and improve the quality of care while quickly determining the proper E/M code for the work performed. I have discussed templates with our local HCFA auditors. They agree that templates help physicians document the level of effort supplied during an encounter with a patient.

My practice developed templates 10 years ago, and we had the layout expertly designed to prevent them from becoming encumbered and intimidating. In addition, we periodically redesign them to meet HCFA documentation requirements. Our templates are organized according to the SOAP system. Every patient encounter is composed of a history (subjective), physical exam (objective), assessment and plan. HCFA refers to the assessment and plan collectively as the decision-making process. The value or intensity of each encounter depends upon the information provided in each section.

The history and decision-making sections are each subdivided into three subsections. The history is composed of the history of present illness (HPI); past, family and social histories (PFSH); and review of systems (ROS). Medical decision-making is divided into the amount of data reviewed or ordered, diagnostic and treatment alternatives, and risk to the patient. The physical exam is not subdivided, so there are seven sections. Our templates encourage physicians to supply data for each of them. For each section, the templates contain the most common questions asked by internists and generalists. Because these questions are preprinted on the template, physicians can check "yes" or "no" for most responses and supply additional information only when needed. A minimal amount of writing is needed, which saves time and maximizes legibility.

As defined by HCFA's 1994-95 E/M guidelines, the value of the physical exam increases with the number of body systems studied. Our templates also reflect the 1997-98 E/M guidelines, which rate the physical exam by the number of accredited maneuvers performed. (For example, the lung exam is divided into inspection, percussion, palpation and auscultation.)

A condensed sample of our template appears on this page. Note that physicians must supply a reason for each encounter, recorded on the template as the chief complaint. The history section from the templates encourage physicians to supply the required information for each of its component sections—HPI, PFSH and ROS. For an extended HPI, physicians may provide information about three concurrent or inactive problems; the template provides space for these. The template also allows physicians to furnish or update past, family and social histories from a prior visit. For the ROS, the template lists each system. After noting the relevant systems and positive responses, the physician can simply check "all other negative" if applicable.

Since we developed these templates, they have been used by numerous practices for whom we have consulted. The templates help improve care because physicians are prompted to examine patients more thoroughly and provide complete documentation. If physicians become distracted during an interview, the template helps them to refocus. In my own office, charting improved dramatically after templates were introduced, and treatment plans are almost always recorded and clearly stated.

Some physicians argue that computerized templates can accomplish many of the same goals as our paper ones. Computerized templates, however, can produce inaccurate information.

Many computerized templates, for example, assume that the work performed by the physician at the previous encounter will be repeated at the current visit. When the patient's name is entered, the computer repeats information from the last encounter with that patient, but attaches the current data to the note. If physicians do not change the information to reflect what is actually done during the encounter, the computer automatically credits them for work they may not have performed.

Another problem can arise when support staff get involved. In many practices, and in compliance with the regulations, physicians need not personally gather a complete history but rather review the information gathered by ancillary staff. Many computer systems do not allow physicians to indicate that they reviewed that information. If the staff takes the history and enters it into the template and the doctor then enters details of the patient encounter, he will get full credit for the history, even if it was never reviewed.

We believe every practice needs to develop some type of templated, uniform system for documenting patient encounters. Use of such templates improves the quality of care, protects the physician in malpractice proceedings and ensures proper coding while saving valuable time.

Dr. Blecker is a practicing nephrologist in Atlantic City, N.J., and a lecturer and consultant on the use of HCFA's E/M guidelines. His newsletter, "Doctor 2 Doctor: A Physician Practice Guide," appears on the Web at www.doctor2doctor.com.

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