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Related Experiment Videos

Use of a template to improve documentation and coding.

E A Rose1, A M Deshikachar, K L Schwartz

  • 1Department of Family Medicine, Wayne State University, Detroit, MI 48235, USA. erose@med.wayne.edu

Family Medicine
|July 18, 2001
PubMed
Summary
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Physician documentation improved with a new template for group A beta-hemolytic streptococcal (GABHS) pharyngitis. However, this template did not reduce evaluation and management (E&M) coding errors.

Area of Science:

  • Medical Informatics
  • Clinical Documentation Improvement
  • Healthcare Quality

Background:

  • Accurate evaluation and management (E&M) coding presents a significant challenge for physicians.
  • Clinical guidelines integrated into patient visits may enhance E&M coding accuracy and appropriateness.
  • A novel template, derived from a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis, was developed to aid documentation and coding decisions.

Purpose of the Study:

  • To assess the impact of a clinical prediction rule-based template on physician documentation and E&M coding for sore throat visits.
  • To determine if enhanced documentation through templates improves the accuracy of coding and billing.
  • To evaluate the effect of templates on treatment decisions for patients with suspected GABHS pharyngitis.

Related Experiment Videos

Main Methods:

  • A comparative study involving 100 office visits for sore throat.
  • Fifty visits were documented using the developed template, while the other 50 used traditional progress notes.
  • Analysis included counting documented history and physical examination items and comparing billed service levels to supported service levels.

Main Results:

  • Templates significantly increased the recording of history of present illness and physical examination items compared to progress notes.
  • The templates positively influenced treatment decisions for patients with a low probability of GABHS.
  • No significant difference was observed in coding and billing errors between the template group and the progress note group.

Conclusions:

  • The implemented template led to more comprehensive documentation of patient encounters.
  • Despite improved documentation, the template did not demonstrate a reduction in coding or billing errors when compared to standard progress notes.