Health Information Management

Tip of the Week: Create a to-do list before you implement documentation templates in your facility

APCs Insider, August 3, 2007

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Documentation templates can accelerate the coding process and help fulfill the coder's mantra of specificity. But the challenge for hospitals is to create templates that strike a balance between these two demands.

Before creating a new documentation template, gather several individuals to help develop the form, according to Gloryanne Bryant, RHIA, CCS, corporate director of coding and HIM compliance at Catholic Healthcare West Corporation in San Francisco.

These individuals should include:

  • The physician who reviews the form and any nurse documentation
  • The nurse manager or clinical nurse specialist, who can represent the necessary clinical aspects of the procedure/service
  • The HIM department's coding supervisor, who can provide health information, documentation requirements and other data capture expertise
  • The coders
  • The compliance manager or supervisor, who can ensure that the template addresses only appropriate questions or information
  • If possible, a graphic designer or a consultant with expertise in user interfaces

To confirm the accuracy of your template, Bryant suggests ensuring the following:

  • The template captures all necessary information
  • A coding compliance specialist reviews the template
  • A coder reviews the template
  • The template is customized enough to be patient specific

(The above tip appeared in the August 2007 Briefings on APCs).

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