Yesterday I addressed the possible caustic demeanor of insurance companies towards template based EMR documentation methods. Definitely something worth considering when you choose an EMR. How they document and the type of note that it creates matters to the insurance company, matters to you reading the note later, and to some extent the doctors who receive your notes on a referral.
Today let’s look at another possible problem with the ugly template note that many EMR systems like to employ (Note: The Jabba the Hut EMR vendors LOVE this type of note). This was sent to me by another reader (Yes, I have the best readers).
I know that Medicare RAC auditors apparently love the EMR systems as practices seem to be hanging themselves with poorly maintained patient notes; (ie. “sutures healing nicely “ in a current note for a surgery that is 2 years old). I guess some insurance payers are jumping on that same wagon of EMR note distrust as the RAC auditors.
Now I’m sure that none of those reading this blog would have poorly maintained patient notes. At least not intentionally. The problem with many of the template approaches to EMR documentation is that the above scenario easily happens in a busy clinical practice. Luckily there are a number of EMR software which don’t use this poorly designed template note systems.
As they say, Buyer Beware. It’s never been more true than when selecting and purchasing an EMR.
While I can appreciate your point I think you have used the word template too broadly. I work for a Vendor that produces chief complaint based templates for documentation of Emergency Department care. Each template must be individually completed with no ability to have a “one-click normal exam” for instance in our electronic products. We also easily allow clinicians to document items not directly associated with the patient’s primary complaint. We never force our clients down a documentation pathway. What you are referring to, I believe, we commonly call macros. They are not templates. They are however, pre-determined notes that do not vary from patient to patient when the doctor wants to note commonly experienced scenarios. Those types of solutions should cause potential buyers great concern. But please don’t turn hospitals and doctors away from a good template based documentation solution over a term applied incorrectly.
Deon,
Macros are a similar concept and could have the same challenges.
I think that I make it pretty clear in my post that it’s the poorly designed template note systems that are the problem. Not all template based note systems are poorly designed. Just some of them.
If it wasn’t clear, I appreciate you clarifying it for people who read this post.