Electronic medical record (EMR) templates can be a useful tool for clinicians to create truly defensible documentation—as long as they don’t rely on them too much.
“Templates should be customizable for each patient, not just placed in the record as a canned product,” Sheila Sizemore, director of advisory and consulting services at Corridor Group, said during a webinar Wednesday. “I think that the key here is balancing the template use with good clinical narrative summaries.”
The webinar’s aim was to help home health agencies learn tips and best practices for creating documentation that can withstand scrutiny from surveyors and other auditors, and prove that an agency is executing on a plan of care linked to the patient’s diagnoses.
This is a basic definition of “defensible documentation,” said Luke Rutledge, vice president of client services at Homecare Homebase, a Dallas-based company that provides an end-to-end cloud-based home health and hospice software platform. Homecare Homebase sponsored the webinar.
Defensible documentation is of increasing importance, given the intense scrutiny that home health agencies face from a variety of regulators that can demand repayment of Medicare dollars deemed to have been improperly reimbursed, Rutledge emphasized. CMS has recovered $29.4 billion for the Medicare trust fund since 2009, he noted.
Connecting the dots
Some agencies might shy away from using templates because they could lead to vague documentation that is not defensible, putting the agency at risk for monetary penalties or other repercussions. However, they’re not dangerous as long as they’re used correctly and in fact can save time.
For example, EMR templates can be beneficial when performing tasks like following an IV procedure or complex wound care, Sizemore said during the webinar.
Yet, the use of templates and checkboxes should be balanced with free-texted narrative components in the documentation, the webinar panelists agreed.
A good narrative should demonstrate a clinician’s critical thinking ability, and show how care is helping a client make progress toward a particular, measurable goal, said Michele Berman, director of clinical practice at Pennsauken, New Jersey-based Bayada Home Health Care, one of the largest providers nationally.
Bayada balances the use of checkboxes and more narrative documentation by stressing to its employees the importance of using the International Classification of Functioning (ICF). The ICF is a framework for describing of health and health-related states first published by the World Health Organization in 1980.
“We found it provides a great format to drive critical thinking and paint that picture of health and disability,” Berman explained. “We really try to teach the clinicians to use the templated areas and put all the puzzle pieces together to come out with a really good picture that connects the dots.”
Written by Tim Regan