The new template was designed by a former ED physician.
Front-line emergency departments facing an onslaught of patients suspected of contracting the novel coronavirus that causes COVID-19 now have a new tool designed to help them quickly diagnose patients.
The new tool is a documentation template that can be programmed into electronic health records (EHRs) to capture all the elements that will accurately record the patient’s condition, while at the same time providing information needed for billing.
“I’m an ex-emergency physician, and it came to me at 4 a.m. earlier this week that the one thing I am really good at is documentation,” said the template designer, Dr. Erica Remer. “Why don’t I design a documentation template for front-line providers to be able to tell the story and capture the elements they need for billing?”
Remer said the template, which will continue to be updated, was borne of her desire to help during the pandemic, which, according to recent news reporting, has claimed the lives of more than 4,000 Americans.
Remer, a member of the American College of Emergency Physicians, earlier posted a request for collaborators to review and edit what she described as her “jumping-off draft.”
“I tried to anticipate what dealing with COVID-19 will look like, not only tomorrow (everything is moving so fast!), but also six months from now,” Remer said.
“The intent is that anyone can bring it into their EHR to capture all the information needed for documenting the care of the COVID-19 patient to clinically communicate to subsequent providers, for coding and billing on the professional and technical sides, and for epidemiological purposes,” Remer explained. “Please feel free to use it in your organization. You may make any adaptations you want, but if you do so, make sure you do not remove elements necessary for appropriate professional and technical billing.”
Contributors to her documentation template included the following:
Richard Gregg, MD, FCCM, FACP
Susanne Hardy, DO
Shariq Iqbal, DO
Joshua Mirkin, MD
Dan Robinson, MD, MHPEc, FACEP
William Weber, MD, MPH
Remer cautioned that her documentation template will likely need regular updates, as the COVID-19 medical environment is changing on a daily, if not hourly, basis.
Vaccines have been in the news recently, making it a good time to take a look at our coding for vaccinations. In our Alphabetic Index,
I had the pleasure of attending the annual California Health Information Conference in Long Beach, California, as an attendee and as a speaker, last week.
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