Templates are helpful for the provider when writing progress notes in a patient’s chart. However, with the power of templates comes great responsibility: We must edit the templates for each and every new note.
Insurance companies can, and will, deny diagnoses based on conflicting or incomplete documentation tied to the use of templates by providers — even if the patient clearly met criteria for a diagnosis.
Here is a specific example:
A patient presents to an urgent care clinic with progressive shortness of breath and chest pain; they were transferred to our ED.
The ED provider documented the following, using a template:
PULMONARY
Effort: Pulmonary effort is normal. Tachypnea present. No respiratory distress.
Breath sounds: Normal breath sounds. No wheezing, rhonchi, or rales.
Comments: Obvious respiratory distress with retracting and wheezing. Tachypneic. Speaking in 2-3 word sentences.
History and physical provider documented, using the same template the ED provider used above:
PULMONARY
Effort: Pulmonary effort is normal. No accessory muscle usage or stridor. No respiratory distress.
Breath sounds: Normal breath sounds. No wheezing, rhonchi, or rales.
Comments: She has wheezes. She has no rales. Increased WOB, prolonged expiratory phase, expiratory wheezing bilaterally. Patient is in moderate respiratory distress.
Assessment and plan:
Acute hypoxic respiratory failure in setting of COPD exacerbation.
Acute exacerbation of chronic diastolic CHF.
Notice how the ‘comments’ area of each template and provider documentation contains descriptors of the patient that are not consistent with the rest of the documentation?
It may be obvious which parts of the above pulmonary assessments are built into the template: The first two lines, effort and breath sounds, are in the template and were not edited by either the ED provider or the attending who wrote the H&P. The admitting diagnosis of acute hypoxic respiratory failure is supported by the provider documentation, but the descriptors from the template, which were not removed, do not support that diagnosis.
Of course, the insurance auditor noticed the conflicting documentation and denied payment for acute hypoxic respiratory failure. We spent a great deal of time appealing this denial but we ultimately lost the diagnosis of acute respiratory failure from this chart.
The take away:
Templates are ready to go with descriptions of your patient’s status before you even begin documenting.
If you document using templates, make sure you are updating them with an accurate assessment and diagnoses relevant to the patient’s condition which, very importantly, includes removing the parts of the template that are not consistent with the patient presentation and level of care received.