Patient Notes Templates and ICD Codes: Simplify Your Life

Patient Notes Templates

Many emergency departments use template notes - they have a huge cabinet with different notes tailored to the chief complaint, e.g. CP note, abdominal pain note, leg pain note, etc. Questions that have to be asked are on the front page and the back page lists the required tests for a particular complaint, differentials and treatment suggestions. Even if you are very tired, you can just glimpse at the note, and you know what to ask and what to order.

T-System offers ER and outpatient template notes. Download an example of DM visit (PDF file). DocAroundTheClock, who is an ER physician, shares his experience with the T-system templates.

I designed my own Sample Admission Notes for the Most Common Conditions, and they are focused on inpatient medicine.

ICD Codes

Family Practice Management journal provides similar and even more variable templates in their toolbox section.

For example, you can review and download the ICD codes: FPM Short List of ICD-9 Codes or FPM Long List of ICD-9 Codes

According to Kevin MD, finding ICD-9 codes can be done easily with Google. You can use various ICD-9 databases, but you can also Google for the appropriate code by adding "ICD-9" to the query. This suggestion seems to be best idea because it is the simplest one.

Tips for Medical Documentation and Coding

(Copied under the Creative Commons License from KidneyNotes.com)

Documentation and coding are not taught well in training programs. When I started practicing, I was frustrated by my lack of knowledge about coding and I dislike mindless repetitive paperwork, so I designed my own templates for outpatient and inpatient consult, admission, and follow up notes. Since they're individualized, they're a pleasure to use. The templates save me hours per week, ensure that I can always code at the highest level, and allow me to concentrate on the most important parts of the note, the assessment and plan. Here are tips I found helpful:

1. Print out and read the Center for Medicare and Medicaid Services 1995 Documentation Guidelines for Evaluation and Management Services.
2. Do the same with the 1997 Documentation Guidelines for Evaluation and Management Services.
3. If you have a Palm, download the demo for Stat E&M Coder at statcoder.com. This program allows you to punch in elements of the history, physical exam, and medical complexity and shows you what level you can code. It makes the 1995 and 1997 E&M Guidelines much easier to understand.
4. Using a word processor or spreadsheet, craft a note template which includes checkboxes for the parts of the history, review of systems, and physical exam that you would typically perform or that would be easy to complete.
5. Use Stat E&M Coder or the Guidelines to ensure that you have all the elements necessary to code at the highest level (assuming a case of appropriately high complexity).
6. Design different templates for consults, new patients, and followups. (My templates are 3 pages for new patients and consults and 1 page for followups.)
7. Put your contact information at the bottom of each template.
8. Print the templates and copy them onto progress note paper if needed. Similar templates could also be designed for dictated notes or electronic medical record systems.

It takes some time and effort to create the templates, but it's worth it.

Study Aids for various CWRU clerkships:
5 x 8 index card for tracking your patients' hospital courses and more.

References:
What is High Complexity Medical Decision Making?. KidneyNotes.com.
Patient Care Documentation Forms. ACP Online.
In The Eyes of Medicare, You are a 99223. The Happy Hospitalist, 11/2007.

Updated: 11/27/2007