It is vital that the provider plays an active role in designing the templates that he or she will use for chart documentation. However, many providers express that they don't know where to start. It is important to have a strategy so that the templates are complete, flow, and don't become a hindrance to the provider's work flow.
Unintentional risks of poor template design:
1. Higher Level E&M Codes
- Templates should represent all levels of E&M services for both new and established patients.
2. Templates that are not customizable
- Include "other" fields or space for free text so that each note is personalized to the patient.
3. Cloned Documentation
- Do not copy/paste an entire note. Only copy/paste the data that will not change.
4. Developing Documentation Bad Habits
- Documenting the same things on every patient; Using Copy/Paste from Previous Visits
Incorrectly; Temptation of Shortcuts; Authenticating/Signing Notes without reviewing.
5. Unclear Authentication of who performed which portion of the Patient Encounter/Chart Note
- All involved in patient documentation must list name/credentials/date/signature on the note.
Four Basic Principles for Good Template Design
1. Contrast
- Use bold, italics, different font sizes, and different colors to differentiate headers from non- headers and content.
2. Repetition
- Consistency leads to organization and unity of your templates. Have consistency in
placement of visual elements, check boxes, etc.
3. Alignment
- Nothing should be placed on the template just because there happens to be open space.
Everything should be aligned, evenly spaced, and there should be visual connection from
start to finish.
4. Proximity
- Space to respond or elaborate via free text should be close to the template items that it
relates too.
One last helpful hint:
Apply the 80/20 rule. The most common content, which you feel is going to be used 80% of the time should be in the template. The other 20%, that is only used a smaller percentage of the time should be free texted so that the note is personalized to the patient.
Remember not to let templates drive your documentation and E&M code choices. Clinical judgement needs to be the driver! The only person that can do that is the Provider!
