Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health...

Area of Science:

• Emergency Medicine
• Health Informatics
• Clinical Documentation Improvement

Background:

• Clinical documentation in emergency departments (EDs) is vital for medical decision-making, patient communication, and quality/billing measures.
• Variations in documentation practices are common, despite evidence supporting note template standardization.
• A nine-hospital health system sought to address these variations through a standardized ED note template.

Purpose of the Study:

• To measure the utilization of a standardized ED note template.
• To assess the impact of the standardized template on coding performance.
• To evaluate the effectiveness of standardization across a multi-hospital system.

Main Methods:

• A retrospective, pre- and post-implementation study design.
• Development of a standardized note template through multi-disciplinary consensus.
• Analysis of ED visit documentation and billing codes before and after template implementation.

Main Results:

• Prior to implementation, six legacy templates were in use, with the most common used in only 36% of visits.
• Post-implementation, 82% of ED visits system-wide utilized the single standardized note template.
• A 1% increase in highest acuity coding and no change in second highest acuity coding were observed.

Conclusions:

• A greater than twofold increase in standardized ED note template use was achieved.
• Multi-disciplinary stakeholder engagement was crucial for successful template design and EHR integration.
• The standardized template implementation led to better-than-anticipated coding performance.