Creating and Using Templates is Vital to Accurate Nurse Documentation

Under APCs, nurse documentation has taken on a new level of importance. If its not done correctly you wont get credit for the services. Experts agree that the best way to provide solid documentation is through a preprinted format system: templates.

Franz Ritucci, MD, DABAM, FAEP, president of the American Academy of Ambulatory Care in Orlando, Fla., says, The easiest way to meet documentation requirements, and what is being recommended, is to have a preprinted form that the nurse is obligated to fill out. It meets the insurance needs; it meets the quality assurance needs.

Although there are no nationally accepted standards for nursing documentation to support APC coding, nurses are still expected to provide assessment notes for each patient consistent with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and nursing specialty standards. At the same time, nurses must ensure that any service performed and billed with the HCPCS codes is legibly documented and that the patients medical record supports medical necessity, explains Laura Siniscalchi, CCS, CCS-P, CPC, education coordinator at Beth Israel Deaconess Medical Center in Boston.

The best way to meet all these needs is through templates that provide in-depth documentation while at the same time are easier on the nurses. Instead of handwriting pages of notes they can instead check, circle or fill in the blanks on the templates.

One of the biggest problems you have in emergency rooms is nursing documentation, explains Cheryl Probst, RN, president of Emergency Nurse Documentation System (ENDS) in Gonzales, La., a complaint-specific template documentation system used in the emergency care setting to record crucial information about patient assessment, interventions, procedures and outcomes. Youre overwhelmed; youre trying to write. But there are things nurses look at all the time but dont write them down. However, if you dont write it down, under APCs, you dont get credit for it. Only surgical and diagnostic procedures and evaluation and management (E/M) services readily identified in the emergency department (ED) record can be billed. With templates, you can do more documentation in half the time.

Complaint-based Templates

Mark Swicord, RN, EMT-P, director of the ED, Archbold Medical Center in Thomasville, Ga., where he is also on the APC Task Force, says, We have always had a diagnosis and complaint-based charge structure. We just turned around and applied the appropriate APC codes to it. It worked very well for the E/M facility-based coding. The next thing we did was create several nurse-specific charges that were procedure based such as IM injections and IV therapy non-chemotherapy. You pull a chart based on the patients complaint and it focuses on complaint-specific assessments and the narrowed areas that relate to that specific complaint. For example, [...]

- Published on 2000-12-01