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. 2024 Mar;15(2):397-403.
doi: 10.1055/a-2301-7496. Epub 2024 Apr 8.

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

Christopher S Evans  1   2 , Barry Bunn  3 , Timothy Reeder  2 , Leigh Patterson  2 , Dustin Gertsch  2 , Richard J Medford  1   4
Affiliations

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

Christopher S Evans et al. Appl Clin Inform. 2024 Mar.

Abstract

Background and objective: Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.

Methods: This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation.

Results: In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity.

Conclusion: We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

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Conflict of interest statement

None declared.

Figures

Fig. 1
Fig. 1
Adoption of standardized note templates by month.
Fig. 2
Fig. 2
Distribution of the Evaluation and Management (E/M; citation 13) billing codes for academic and community-based practice settings, before and after implementing standardized note templates.
Fig. 3
Fig. 3
Monthly utilization of new standardized note template by emergency department practice model.
See this image and copyright information in PMC

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