Documenting Multiple Injury Visits

Summary

To clearly document multiple injuries, keeping information on each injury distinct, certain parts of the visit must be documented separately for each injury. However, there is no need to change templates back and forth on each tab. In all likelihood, it will only be necessary to change Templates once, and that is on the HPI tab. If both injuries are covered by the same template, it will not even be necessary then.

How to Document Multiple Injuries

Here is how to manage a multiple injury visit on a tab-by-tab basis.

  • HPI tab: The HPI tabmust be repeated for each injury, because the information reported for each injury will be different, even if they are to the left and right of one body part (say, left and right knee), and it must be kept separate. Set the correct Template for the first injury, and enter the details for it on the HPI tab. If the second injury better fits a different Template, change the Template appropriately. Then, enter the details of the second injury on the HPI tab. Entering by this procedure will put all of the information for each injury together in a single block.

  • PMH tab: This information is entered once for the visit. Nothing on this tab varies by injury.

  • ROS tab: This information is entered once for the visit. Nothing on this tab varies by injury. It might be that the templates for two disparate injuries will not have the same buttons enabled, but there is no need to change templates. Simply check the box to the left of any disabled button which you want to use.

  • EXAM tab: A separate exam is required for each injury, unless they are bilateral injuries, and both exams are All Normal. See the section on bilateral injuries below. It is not necessary to change templates, even if the injuries fit with different templates. If the exam button for one of the injuries is not enabled, check the box to the left of the button to enable it.

  • ASSESSMENT tab: The Assessment button on this tab will display choices appropriate to the currently selected template, and can be used to document the related injury. For the injury not selected by the current Template, the Template can be changed, but it will probably be easier to utilize the Any Wizard button. Clicking that button displays the lists of all Assessment Wizards, for all body parts. Search for and select the proper one, then document the second injury. The ASSESSMENT tab includes other methods of entering diagnostic codes, but these two are the most efficient.

  • ORDERS tab: It is most likely that the ORDERS tab will include what is needed for both injuries without changing templates. The list of pain medications for an upper extremity injury will be the same as for a lower extremity injury, etc. If an item is needed that is not displayed, use the Any Med or Any Wizard button to locate it.

  • PROCEDURES tab: If a needed item is not displayed on this tab, use the Any Wizard button. Suppose, for example, that there are two injuries, one to a knee and one to an elbow. The currently selected Template is for lower extremity injuries, but the patient needs an elbow brace. Click Any Wizard to see all Procedures Wizards, and select the Upper Extremity Braces Wizard. Select the needed brace from the Wizard that is displayed.

It might be tempting to use the Basic Default Template for multiple injuries, or to create a multiple injury template. Either of these can be done, but in the end, it is unlikely to make the process of documenting multiple injuries easier and in fact, it might make it more difficult. Even if you have a single Template that covers body parts for different areas of the body, it will still be necessary to document each injury separately. The most likely result of trying to have a single template to cover all possibilities is that you will have much longer lists of choices, making it more difficult to find the ones you are after - and that defeats the entire purpose of Templates!
Special Cases
  • Bilateral Injuries: A patient might present with bilateral injuries, that is, both knees, both ankles, etc. When this happens, the two injuries must be documented separately on the HPI and EXAM tabs. The reason is the same for both elements of the visit: the two injuries will have different details. For example, with bilateral knee injuries, one knee might have a laceration, but not the other. The pain level might well be different for the two, and other symptoms such such as swelling, numbness, abrasions, etc. will be different. The same is true for the exam. If both left and right exams show no problem, then, a single bi-lateral All Normal wizard can be run. Otherwise, separate exams are required. An additional reason for this is for proper coding. Two exams will count for more than one. (A single bi-lateral All Normal Wizard can be set up to give the correct number of bullet points for two exams.)
  • Old and New Workers' Comp Injuries: If a patient presents for a new Work Comp Injury, and also wants an earlier injury looked at, two visits will have to be logged, and the injuries documented separately. The reason is that injury visit are linked to incidents. The incident carries certain medical information specific to the injury, and therefore, the patient must have a visit record for the new injury, and a second visit record for the previous injury, even though both are addressed in a single visit. If both injuries are documents on a single visit, and at a later date someone needs to know about the second, they will not find the information from that visit since it will be associated with a different injury. In addition, billing information is carried in the incident record, not the visit. It is quite possible that the employer has changed Work Comp carriers, and that different payers are responsible for the two injuries.
  • Workers' Comp and Urgent Care Injuries: It might happen that a patient has two injuries, one of which is Workers' Comp and the other Urgent Care, or Private Practice. A separate visit will be required for each. The reasoning is the same as for Old and New Workers' Comp injuries, but more compelling: there is absolutely no way the same payer should be invoiced for both.