In this week’s newsletter I would like to open the discussion on templates. Templates are something I have been preaching and teaching for several years. The reason I do this is because of one simple thing: my memory.
Unlike most of you out there, I tend to forget things from time to time. Sometimes its simple things like we we’re supposed to go to a party on Tuesday. Or one of the kids has a football game Thursday night. Or my daughter needs me to take her to dance at 4:45 today. I’m sure none of you out there have ever had trouble remembering these types of things.
But we tend to do better about remembering medical things. What antibiotic do you use for strep throat? How do you treat status asthmaticus? These things we don’t forget. Here’s another one: Always put in a complete Review of Systems on a new patient. This was a $2,000 lesson I learned in my audit a few years ago.
We have imperfect memories and need ways to remember important things. Whenever you write your progress notes, you must have some sort of template. Many of you use paper templates. Many of you have screens that are templates in your EMR system. I know almost all of you have a mental “template” you use when hand-writing or dictating a note.
We all have and use templates. Over the next few weeks we are going to talk more about how we can make and design our own templates for our practices. By doing this, we can make our lives MUCH easier and ensure that we are not forgetting the “important” stuff.
Coding Growth Strategies Improvements.....Con't
Last week we discussed some of the new changes in this year’s Coding Growth Strategies. We’ve tried to bring our educational system “full circle” by completing our training not just in coding but also documentation. In the first set of examples we discuss several notes from an “auditing” point of view. We analyze the notes and look for good and bad notes. In the bad notes, we try to figure out what is missing from our documentation.
When we start the second set of examples, we now start actually writing notes. We use templates that I’ve created to learn how easy it is to document accurately. The entire group watches the video example. The templates provided in the workbook have the chief complaint and history of present illness written down as provided by the patient. Now we talk in depth about exactly how much physical exam, history, and decision-making it takes to document the correct level of service.
I really enjoy teaching this to physicians. Most of the physicians we talk to have been in practice for many years. It is entertaining to see how difficult it is to sit down and try to write a “good” note in front of me! You all have been writing notes for years. Great notes! But now that we have started to learn how easy it is to code higher level of services, that first group exercise of writing a note seems to be very hard for everyone.
Don’t worry! We struggle through it. It usually takes several minutes before everyone is finished. We then grade each other’s notes and find that most people still have put in too much of something or not enough of other things. That is perfect! This is where the real learning starts. We cover another patient. Then another. Then a new patient. Then an established patient. We practice documenting patients with no history. Other times we practice documenting notes with no exam. Over and over until everyone is an expert.
Over the next few hours of patient examples, we continue this cycle of auditing and correcting notes then writing our own. By the end of this section, usually the entire audience can “knock out” a 99214 or 99215 note in 20-30 seconds. Now I know that we are shortcutting some things and it may not be that quick in your practices, but by the end of the example section you will be an expert. By expert I mean that you can quickly know and complete the requirements for high level notes.
You will know exactly which patients are 99214s and 99215s as soon as you start talking with them. And when you write your notes you will know exactly what is required so you can get your documentation done as quickly as possible and move on to the next patient.