Documentation Guidelines
Purposes of Medical documentation:
Patient care – notes must be timely, and succinctly and accurately convey the current status and plan for the patient
Legal – notes must be accurate and with sufficient detail
Billing – Documentation must be sufficient to support billing. The EMR is designed to optimize billing by making it easy to include many elements in documentation. However, this has fostered the idea that “more it better”, leading to the note bloat phenomenon in which notes frequently contain redundant, contradictory, superfluous, and/or out of date information.
Some things that many people are doing that ARE NOT ALLOWED:
Copying forward major elements of notes from prior documentation:
This makes it unclear what has been performed that day (i.e. did you in fact check all the same elements on exam and the patient responded in exactly the same way, or did you just copy exam forward).
It also leads to the “note bloat” phenomenon which makes it difficult to find relevant information that is needed for patient care.
Each note should be started with a blank page and a new blank template and then ONLY a few key elements should be copied in from other places in the chart.
Pasting things into medical record from outside chart: In EPIC, you can see where copy/paste elements originate. If you write a note in word or other outside program and then copy into EPIC, it will appear as “copied from outside chart”. This will lead to legal problems as it will raise suspicion that the note may have been copied from another note in the chart that cannot be easily identified, or that it may have been copied from another patient’s chart, which is absolutely forbidden.
Copy/Pasting in sections from other authors without appropriate attribution: It may be appropriate at times to include some elements of other’s notes. If this is done, it should be clearly stated where/when/who that information is coming from.
key principles
MORE IS NOT BETTER. Include only information that is relevant for patient care. DO NOT pull in extraneous info and avoid ‘Note Bloat’. The more irrelevant detail you add, the harder it is to find the relevant information.
DO NOT COPY FORWARD – You should start each note with a blank page, then can bring in the basic note template and fill in the details new each day.
DO NOT use “NORMAL EXAM” TEMPLATES. The exam documented in the notes should EXACTLY match the exam that you actually performed on the patient that day. You should start each note with a blank exam and then fill in those elements that you performed. For the daily progress note templates, the Neuro exam section has been pared way down to just major categories (delete those that you have not examined that day and include only what you did). If you want the more detailed template, import phrase “.UMHNEUROEXAMTEMPLATE”
Note templates are designed to make documentation easier and more accurate. Unless there are elements that you know are required, you should delete any sections of the templates that are not relevant for the patient at that time.
You are responsible for EVERYTHING that is in your notes. The notes serve as a way to organize your thinking and demonstrate that you have reviewed relevant information and acted on it. It is not enough to have a medication list or labs pull into your note. Putting info in your note implies that you have reviewed it and acted accordingly.
If you are giving the patient a medication, it should be related to a problem that is on the patient’s problem list (implied in this is the principle that you should know what all the medications are for).
The A&P should bring together all data into your ASSESSMENT of the patient. DO NOT restate the patient’s entire HPI and hospital course at the beginning of the A&P section.
Every patient should have a progress note every day – This is also true for patients admitted the day prior. It is true that the H&P is the note used for billing on the first day of admission. However, for patient care purposes the resident who is taking over primary care of the patient should write a short progress note on day 1 that outlines patient’s current status and the plan that incorporates the discussion on rounds (which may be different from the admission plan in the H&P). A lot happens on day 1, and this should be documented. Writing a note will also help ensure that the team has reviewed the labs, meds, etc. that day.
Remember that you can (and should) always add a note when indicated for patient care – If there are major events/changes that happen in the afternoon, they should be documented when they happen rather than being saved to include in the next morning’s note.
You should view your notes not as a daily task that just needs to be completed as quickly as possible, but rather as a permanent record of the care that you have provided.
If that record is of poor quality, patient care and your reputation as a careful and trustworthy clinician will suffer.
Just because many notes in the medical record are of poor quality, this is not a reason for us to join that substandard group.
How to optimize medical documentation in this new age of electronic medical records is an ongoing national discussion. We should continue to try to improve the efficiency of the process, but without sacrificing the quality of the final product.
If you have suggestions for changes to exam templates or “best practices” to be passed along, please share them.
Problem Lists
Principles for use of Problem Lists:
Add the active patient problems to the list
The diagnosis of the problem should be changed as necessary when new information is received. (Example: On admission, the problem may be “weakness”, then the next day when you have determined the cause, it can be changed to “Right MCA stroke” or “Guillain Barre”, etc.)
Keep the list accurate and up to date.
If a problem is no longer active, it should be “Resolved” (Ex: The UTI they had 3 years ago)
If patient has multiple entries for the same problem, duplicates should be deleted (Ex. “hypertension” and “essential hypertension”)
In “details” section under each problem, put in ONLY information that:
Will remain true for an extended time
Is likely to be relevant for future care of patient
Some examples:
under stroke: location and likely etiology
under migraine: age of onset, triggers, and previously tried medications
under pneumonia: culture/Xray results, date of onset and planned date of completion of antibiotics
DO NOT put in information that is specific to today. Unlike a daily progress note, the problem list is a live document, so stating “today” or “yesterday” has no meaning and becomes misleading.
Keep it succinct and relevant. DO NOT add in all details of the presentation or every lab/imaging result.
How to use Problem list appropriately in Inpatient Progress Notes:
Following the above principles, update the Problem List as relevant information becomes available or changes (this can be done at any point in the day)
Each morning: Start a new daily progress note and import Problem List with details (this is done automatically in the template)
Right click on the imported problem list and “make editable” (Note: you can do this with any element in the note – use this functionality to remove things that may be irrelevant while keeping things you want)
Under each problem: Add in the relevant daily updates and Plan for the day.
Each problem should appear only once, with the relevant data, assessment, and plan for the problem grouped together. Information should not appear in more than one place in a note (this both causes Note Bloat, and increases the likelihood of conflicting information)
EPIC TIPS
How to save EPIC orders to PDFs and how to attach them to MyPortfolio messages:
Dr. Jin put together this PDF guide. He uses it to send orders to patients via secure e-mail or MyPortfolio along with Doximity fax for records and orders to insurance companies / testing centers. You will find it particularly helpful though when a patient needs to get an order quickly or if there are snafus on the administrative side.
Some helpful links for customizing or trying to figure out how to do things in the UMMC EPIC system:
A Tip Sheet Library for UMMC EPIC {Archive from Nov 2021 and prior}
A description of changes and updates to the UMMC EPIC system
EPIC In Basket management:
The In Basket is designed to support the timely response to patients, staff and patient information. The expected work flow is that you will review these daily, take appropriate action and “Done” them to get them out of you in basket. The speed with which you complete messages is a metric that is tracked by EPIC (and may influence your compensation in future, so best to develop good habits now).
If you feel you need to follow up on something in the future, you can make a patient reminder for yourself which can be delivered at future time. (see tip sheet)
Results can be sent to patients as Epic patient message or in a short letter (which you can route to your administrative assistant for mailing).
You could place limited important information on test results and need for follow on the patient’s problem list. This would then be easily accessible not only for you but anyone else looking at chart.
Remember you have a Sent Messages and Completed Work tab on bottom left of in basket. This lets you review recent items without having to “store” them in the In Basket.
neurology note templates
Templates are continually being updated. You should always start your notes with the Neurology System Templates (.UMHNEURO…) so that you have the most up to date templates.
.UMHNEUROEMUDCSUM
.UMHNEUROEMUHP
.UMHNEUROEMUPROG
.UMHNEUROGENERALHP
.UMHNEUROGENERALPROGNOTE
.UMHNEUROGENERALDCSUMMARY
.UMHNEUROSTROKEHP
.UMHNEUROSTROKEPROGNOTE
.UMHNEUROSTROKEDCSUMMARY
main points on nihss documentation
For ALL ischemic stroke patients, there should be an NIHSS documented in the Flowsheet section at least 4 times:
Admission, the next two mornings, and discharge (obviously if they have a short stay, it will be fewer).
After you put it into the Flowsheet, it can be pulled into the note from there with the phrase: .FLOW[7091970:LAST
A tip sheet is attached
useful overview toolbar buttons
UMMS CR IP Clinical Overview MD -- good overview page, with medications, 24h vitals/labs/infection issues, L/D/A, etc
UMMS Rounding Report
UMMS RR CC DVR -- great display of vitals and neuro exam
UMMS PATIENT SNAPSHOT (HTML/CSS) -- patient snapshot (the default outpatient overview page)
UMMS RR CC NEURO MONITORING -- another vitals/neuro option
UMMS CR Therapy Discharge Recommendations -- therapy recommendations (PT/OT/SLP)
UMMS CR IP SLP Eval
EPIC tobacco cessation e-referral tool
Podcast to help navigate the new EPIC tobacco cessation e-referral tool.
Documentation for billing compliance
Billing compliance requirements for documentation are different for Inpatient and Outpatient care. See attached slides on:
Inpatient billing: requires all components of History, Physical, and Medical Decision Making to be documented fully for high level billing.
Outpatient billing: Level of billing is based on the complexity of Medical Decision Making (MDM). Therefore, it is important that documentation reflect the work that is done in the areas of:
Number and complexity of problems addressed.
Amount and/or complexity of data reviewed and analyzed
Risk of complications and/or morbidity or mortality of patient management.
utilizing interpreter services
Communicating with patients in their preferred language is a basic patient right and a Joint Commission requirement.
Find out if your patient or surrogate decision maker requires an interpreter on the left hand side of their EPIC page
If you are bilingual in the patient’s preferred language, you can provide language concordant care to obtain consent.
If you are not bilingual in the patient’s language, you may not use a family member, guest or other UMMC employee to interpret. You must obtain either a hospital-based Qualified Medical Interpreter or a Qualified Medical Interpreter using the Video Remote Interpreter device (VRI) or the Interpreter phone to obtain consent.
a. Telephonic interpreter: 8x5452
b. Video Remote interpreter: Page TALK (8255)
c. In-person interpreter: Page TALK (8255)
Print the appropriate consent form from FormFast
Speak directly to your patient or surrogate decision maker in short but complete sentences. Pause to allow the interpreter to interpret.
There are 2 lines underneath the provider’s signature line on the consent form. Check the appropriate box. Write the interpreter’s name and/or interpreter # given when using technology.
a. __ Healthcare provider is bilingual and provided language concordant care for consent
b. __ Interpreter used: Name or interpreter # _____________________
Last Updated: January 2023