How to Set Up Provider Charting Templates

If you haven't already done so, please read Net Health Employee Health and Occupational Medicine Provider Charting Overview and Using Provider Charting Templates before proceeding.

For a list of terms specific to Provider Charting, see the EMR Glossary.

Summary

The Provider Charting Template provides a problem-oriented structure for collecting the information needed to generate a charting note. An individual Template is specific to a broad category of complaints such as Back/Neck Injury, Eye Complaint, or Chest Pain. They are fundamentally a set of user-tailored pick lists that, at every point of charting the visit, present the most common choices, depending on the type of problem and the section of the chart (HPI, review of systems, exams, assessment, orders and medications, etc.). These pick lists are driven by brief keywords, called Text Elements. The practitioner selects items from the list each of which causes an action to take place in the system, depending upon the nature of that keyword item.

There are three types of action which a Text Element can trigger:

• The insertion of a brief segment of text, usually 1-3 words.

• The insertion of a larger block of text that can be paragraphs in length, if need be.

• Run an "Charting Wizard" to collect detailed information.

A Charting Wizard is a reusable component that once created, can be associated with any template. Wizards can be comprised of one or more steps which collect input from the user and combine it with pre-defined text to generate paragraphs for insertion in the charting note. The content of Standard Wizards are completely determined by the user when the Wizard is setup (or modified.) The user can determine the number of steps on the Wizard, the type of information collected for each step, the options on lists, and the pre-defined text that is added before and/or after the user responses. Specialty Wizards are fixed in design to let the user perform specific tasks such as adding an element of history, selecting a diagnosis, or ordering a medication.

In addition to the presentation of pick lists through Charting Templates, the system allows authorized providers to establish automated sets of multiple Wizards through what we call "Charting Rapid Chart". A Rapid Chart will execute consecutively any number of Charting Wizards and/or medications and other types of orders. Rapid Charts are designed for complaints that see relatively little variation. A Rapid Chart can be created that is associated with a single tab on the Charting Workspace or which covers much or all of charting a particular complaint.

Visit Level

One important aspect of Charting Templates is the ability to determine the level of documentation you need, based on the E/M code selected for the visit, and the level of documentation required to justify that level of visit. Once you have met the requirements for that level, a red light will turn green, letting you know.

This is not magic. Evaluation is performed in accordance with AMA and CMS guidelines for reimbursement of evaluation and management functions. For this to work, certain information must be entered in the EMR setup. While these factors can be entered for an element directly on the Template, they are most often entered on the Wizards associated with the template.

Basic Default Charting Template

When you work with templates, you will find that many of them have sections that are fairly standard. For instance, the information collected on Patient Medical History (PMH) and Review of Systems (ROS) do not vary much from template to template, whereas History of Present Illness (HPI) and Medical Decision Making (MDM) can be highly variable. Since we want to make working with templates as efficient and easy as possible we have created a way to define a standard setup. We call it the Basic Default Charting Template, and your system came with it already created with common settings. You can, of course, change it as needed.

Enter your most common setting in the Basic Default Charting Template. Then, when you create a new template, you can set elements to use the default settings. With that done, no more setup work for those elements. If you later make a change in your Basic Template, that change will automatically apply to all other templates using the defaults in the affected area.

Setting a template to use the Basic Default is easy: simple check the appropriate boxes to indicate the elements that will use it. In some cases such as ROS, there is one checkbox and checking it will use the Basic Default for all template elements. However, on the PMH tab there is a separate checkbox for the different histories, so you could use the Basic Default for the medical histories while not using it for the social histories. The Medical Decision Making elements get more complicated because elements on different tabs are functionally related. While the checkbox to use the Basic Default for the Assessment tab affects nothing but that one element, Diagnostic Tests, Results, and Procedures are grouped together. You use the Basic Default for all three, or for none. Medications can vary a great deal by template, so the choice to use the Basic Default for it affects only that one element. All the other elements of Medical Decision Making usually do not vary much from template to template, so they are all grouped together. The setup Medical Decision Making tab where you choose the elements that will use the Basic Default makes clear the groupings.

In EMR System Parameters you can indicate the tabs which you typically want to use the Basic Default Charting Template. When you add a new template, the Basic Template boxes will be checked on those tabs. They can, of course, be unchecked when needed.

Copying From Another Template

Selected elements of a Template can be copied from another Template during setup. The Text Elements to copy are selected on an element by element basis:

When you click the button to copy, the application will first ask which Template to copy from, then present the window above for the details. It has tabs that correspond to the ones you see when charting a visit. (The Medical Decision Making tab above includes all the buttons on the Assessment, Orders, Procedures, and Instructions tabs.) You check the boxes for all the Template Elements you want to copy, and the software will copy the list of Text Elements from each to the new Template.

If you want to copy the entire Template select the box next to Copy Entire Template.

While this is typically done at the beginning of creating a new Template, it can in fact be done at any time, and it can be done multiple times. Now, the application will NOT copy a Template Element that already has entries on it. However, if you copied one tab, then later decided you wanted to copy another, that can be done.

It might happen, in fact, it will probably happen, that when you go to copy a Template, instead of the window above, you will get one more like this one:

Notice that it has fewer tabs. Here's why. You cannot copy tabs that are set to use the related tab on the Basic Default Charting Template. The window above has fewer tabs because PMH, ROS, and EXAM are all set to use the Basic Default Template. This might be the typical situation when you are adding a new Template. Here's why. It is probably that you will use the Basic Template for those three tabs on most Templates. To save you the trouble of checking the boxes to indicate this, an EMR System Parameter can be set which will indicate tabs to have those boxes automatically checked when a new Template is added. If at this point in the process you get a window that doesn't have a tab you want to work with, simply exit from here, uncheck the Basic Template box on that tab, then start over copying.

Setting Up a Template

This screen shot shows the basic steps of defining a template.

1. From the Select EMR Charting Template window select a template to work with, or add a new one.

   

2. On the Set Up EMR Charting Template window, choose the Template Elements which are needed for this template. Here, the Template Element was clicked to select "Nature of Problem".

   

3. On the EMR Charting Template Text Elements window, enter the Text Elements which the user can select with this Template Element.

4. On the Set Up EMR Charting Template Text Element window, define each Text Element. This particular Text Element is as simple as they get. It will do nothing but insert the word illness in the charting note(Presenting Problem: Illness). Optionally, a full sentence of text could have been entered, or a Template Wizard could be called to walk the user through a set of predefined steps to collect very specific information.

   

We will discuss these steps in more detail below, but first, let's see a simple example of how this looks to the user. When using a template, the user selects a Template Element for which information is available. Doing so displays the EMR Charting Template Text Elements window with a appropriate list of choices:

This screen shot shows the screen the user would see for the setup example above. There is a checkbox for each of the three Text Elements.

A Text Element can do one of three things:

• Insert Key Word Text, a short segment, in the charting note. The Text Element partially seen above does nothing but insert the word "Injury - Upper Extremity ". (Presenting Problem: Injury - Upper Extremity will display on charting note.)

• Insert a Full Sentence. This can be a sentence, or even more.

• Invoke a Template Wizard. Wizards automate the collection of more complicated information which can include things like multiple choice questions and pick lists. On the [EMR Charting Template Text Elements] window shown above there are three Text Elements. The first two are simple text elements. The third one, Other Problem, is a wizard. (There is no way to tell at this point which are which.) This Wizard, invoked by the Other Item Text Element , is a very simple one that allows the user to type in free form text.

  If a checkbox represents a wizard, that wizard then runs in the Smart Form Charting Wizard window:

A more complicated Wizard would present a list of additional choices to make. When all of the wizards have run, the application generates the charting note segment.

The entire example shown, starting with the two boxes checked, is very simple. It started with the Lead-In "Presenting Problem:". It added the word "Illness". It then appended the text typed in by the user on the Other Problem Wizard: "Also reports persistent upset stomach." Here is the resulting text which gets inserted into the charting note:

This topic includes a discussion of creating Text Elements. Wizards are discussed in the Setting Up Template Wizards topic.

Template Setup

1. On the Home Nav Bar

2. Select Setup/Admin

3. Click EMR Setup.

4. Click EMR Charting Templates to display the Select Charting Template window.

5. Click Add to create a new template, or, highlight an existing template to work with and select Edit. Either action will display the General tab of the Set Up EMR Charting Template window:

6. You may optionally begin by selecting Copy from Another Template to start a new template from scratch.

   1. Click Copy from Another Template to display the Select EMR Template window.

   2. Search for and select the template to copy. This will display the Copy EMR Template window which will show the name of the Charting Template selected in the previous step.

   3. You need not copy all elements of the template. This window allows you to select the ones you want.

      Each tab has check boxes for elements that can be copied. Check the ones you want. Only elements not already present in the current template will be copied. That is, if you copy into an existing template after you have already entered items on some Template Elements, those elements already entered will not be overwritten.

   4. Click OK when done.

7. Enter items on the General tab

   

   Sections on the General Tab	Descriptions
   Applies To	The template can be marked to be available for All Visits, for Work Comp Only visits, or for Non Work Comp Only visits. When the template is selected on the visit, the selection list will include: On Workers' Comp visits: Work Comp Only and Universal Templates. Private Practice visits: Non Work Comp Only and Universal templates. On Employer Services visits: Universal Templates.
   Default New Patient Evaluation Level	This drives the default E/M Level for new patients; i.e. Level 1 = 99201, Level 2 = 99202, Level 3 = 99203, Level 4 = 99204, Level 5 = 99205. When a user selects a template for a new visit, the first thing entered is Patient Type which can be New or Established. When New is selected, the evaluation level entered here will automatically be selected. The default selection can, of course, be changed when appropriate. When documenting in the EMR this section on the Visit tab will determine the type of patient and E&M Level assigned.
   Default Established Patient Evaluation Level	Works as above when provider selects Established for Patient Type.
   Security Rules to be Enforced Always	Each of these three check boxes, when checked, causes the indicated history to be suppressed when the charting note is generated. Standard text will be inserted to make clear that the information was collected, but details will not be included. This information is typically not included on Workers' Comp charting notes because of privacy concerns. The intent of these controls is to allow you to collect history without violating privacy regulations. The Suppress All Personal Past History checkbox applies to the allergies, medications, illnesses and surgery and hospitalization section elements. On the Security / Confidentiality tab of the EMR Parameters window, you may customize the Standard Text that will be inserted when each of the boxes is checked. You can also indicate if you want each box to be checked by default on new templates.
   Override Note Formatting when using this Template	An option on the General tab of the EMR Parameters window allows you to indicate whether or not you want to use SOAP formatting for the charting note. If unchecked, it uses a single narrative format. If your clinic has types of visits that require different formats, perhaps you do PT visits which do not use SOAP notes, this option allows you to override the default. You can either have the Template use the default as set in EMR Parameters, or you can tell it to specifically use the SOAP Format or Single Narrative Format.

8. Each tab other than General and Rapid Charting has one or more check boxes labeled Use Basic Default Charting Template. When the box is checked for a tab all controls will be disabled and the application will use the settings on the Basic Default Charting Template for that tab. While you can't change items on the individual template elements, you do have a choice of which elements to include on this template.

   Do NOT check Use Basic Default Charting Template on an established tab "just to see what happens"! All setup done on that tab so far will be lost, even if you then uncheck it.

9. Enter Template Elements on the History and ROS tabs as described in the Set Up a Template Element section below.

• Enter Template Elements on the Examination and Results tab following the same process.

• Enter Template Elements on the Medical Decision Making tab following the same process.

8. For Workers' Comp visits, set up the single Template Element on the Work Assessment tab following the same process.

9. Optionally, add Rapid Charts to automate entry on the template by clicking the Rapid Charts tab.

   1. Click Quick Add Rapid Charts to display the Quick Pick Rapid Chart for Template window.

   2. This window has a split screen display. The pane on the left, Template Rapid Charting, shows all Rapid Charts selected for this Template. The pane on the right, Available Rapid Charts, shows the list of Rapid Charting you can select for this Template, along with the ICD-10 code associated with each Rapid Charting, if any.

   3. By default, all Rapid Charting are displayed. You can change the list of Rapid Charts displayed by clicking the drop-down arrow beside Type in the upper right of the window. This will drop down a box allowing you to display Exam Set, Order Set, or Full Charting Set Rapid Charts.

   4. Search for Rapid Charting you want in the right pane. When you find one, highlight it, then either double-click or click the Add Rapid Chart to Template button in the upper left of the window.

   5. To remove a Rapid Chart from this Template, highlight it in the left pane, then click Delete.

10. If you want to prevent an existing template from being used in the future, check the Inactive check box, and enter an As Of date. The template will no longer be included on the [Select EMR Charting Template] window when users are selecting a template for a visit.

    You can only delete templates which were entered in error. Once a template has been used on a visit, it can no longer be deleted. Instead, check the Inactive box, then enter an As Of date. The template will not longer be available for users to select.

    

11. Optionally, click Print to review your work. After clicking Print, you will have the option of sending the report directly to the printer or to the Report Previewer.

12. Click Save when done.

Set Up a Template Element

1. On the Set Up EMR Charting Template window select the Template Element for the Template Element you want to work with.

2. On the EMR Charting Template Text Elements window select Add or highlight an existing element and click Edit.

   The information in each column on the EMR Charting Template Text Elements window is:
   Seq	Numerical sequence. You can change the position of a Template Item by using the up and down arrows .
   Template Item	The name of the item.
   Wizard	Used to indicate whether this item is associated with Template Wizard.
   Prob List	Used to indicate that when the user selects this item, it will be added to one of the Problems Lists on the Patient Chart.
   Count	Relates to the E&M level calculations performed by the application.
   Risk	Shows the Medical Decision Making (MDM) risk level, if any. This is also related to E&M level calculations.
   Order	Shows the Check-Out action for this step, if there is one.
   Red Flag	Used to indicate that there is a Red Flag Warning or Alert Message associated with this item.

3. Either one will display the Set Up EMR Charting Template Text Element window.

   1. Use Wizard: Optionally, click the magnifying glass beside this to select a Template Wizard to run for this Text Element.

   2. Keyword Text (required): For all Text Elements, the Keyword Text is the primary identifier for this item, and will appear in the Template Item column on the EMR Charting Template Text Elements window.

      • For a Text Element that has a Template Wizard associated with it, the Keyword Text be the name of the Template Wizard, and will be automatically inserted when you select the Wizard in the step above.

      • For a Text Element that has neither a Template Wizard or Full Sentence Text assigned to it, this will be the actual text inserted into the Charting Note.

   3. Fill Chart with this Full Sentence Text: If you want this Text Element to insert more than a couple words into the Charting Note, enter the longer text here. There is no practical limit on how much you can enter. An entry here will be used instead of the Keyword Text above. The Keyword Text will still be used as the identifying Template Item for this step on the EMR Charting Template Text Elements window.

   4. Bypass this Item when Evaluating for CPT Visit Level: Checking this box will exclude this item when the application performs Evaluation and Management calculations.

   5. ALERT tab: Optionally, enter a warning to be displayed when this Wizard executes.

      • Click the ALERT tab.

      • Check the box labeled This Template should invoke this Red Flag or Alert Warning.

      • Enter the text of the message in the text box beneath Alert Message or Red Flag Warning.

        Alert messages can also be defined when you Set Up a Template Wizard.

   6. Other Items: There are several other items which may be on this screen, depending on the Charting Element you are working with. In the example above, Add This Problem to the Clinical Problem List and Chronicity are items that do not appear for all Text Elements. Some of these items will be "grayed out" if you have entered a Wizard for this Text Element, since they will be defined at the Wizard level instead of here. This is the full list of items which might appear on this window:

      • On the Diagnosis Codes tab you can assign ICD-10 Codes

      • Add this Item to the Clinical Problems List: The Problems List referenced by this item varies, depending on the Text Element. Instead of Clinical Problems, it might be Social History, Allergies, Current Medications or others. The Patient Chart which carries the full history of the patient, includes a number of problems lists. If this box is checked, when the user selects this Text Element on a visit, this item will automatically be added to the indicated list.

      • Chronicity: (HPI, PMH/Problems and Illnesses, Problem Assessment) This drop-down list allows the user to designate this problem as chronic, acute, self limiting. This affects the risk level during E/M evaluation by increasing the number of chronic conditions, displayed on the Assessment tab.

        

      • Positive/Negative: (ROS, Test Results,) Positive enters "Claims" plus the Keyword Text. Negative enters "Denies" plus the Keyword Text. Pick provides a checkbox for the user to select either Positive or Negative at the time of the visit.

      • This Counts As: ? "Bullet Point" Elements for purposes of evaluation Examination - (Organ Systems, Musculoskeletal) This indicates how many bullet points will be used for this examination when E&M calculations are performed.

      • This Counts As: ? Presenting Problems for purposes of evaluating Complexity of MDM - (Problem Assessment) This is used to help indicate the level of complexity in E&M calculations. 1=Problem 2 -Getting Worse, etc.

      • This Count As: ? sources of Data for purposes of evaluating MDM Complexity - (Orders/Diagnostic Tests) Used for calculating the complexity of the visit when E&M calculations are performed. Data sources include tests, requests for patient chart from another provider, labs, radiology, etc.

      • MDM Risk Level: (MDM, Medical Procedures) Used for calculating the complexity of the visit when E&M calculations are performed.

      • Check-Out Action: (MDM, some Orders, Medical Procedures ) The list of options offered here varies by Template Element. It allows you to indicate activities to be performed after the provider sees the patient. When a selection is made here, an order record gets created when the Template Step is executed. Order records can be seen by clicking the Orders button on the Menu Bar. While this is labeled Check-Out Action, that means it will create an order to be carried out by check-out, not necessarily at check-out. Like any orders, these are accessible through Orders Management.

        

      • Auto-Charge: Text Elements for certain Template Elements (ex. Medical Procedures and Orders) allow you to automatically add a charge to the visit. When available, check the box beside Auto-Charge. Then, the table icon to display the [Select Medical Activity Code] window. Search for and select the appropriate activity to be billed.

        Many of these items can be set at the Wizard level instead of here. If a Wizard is associated with this Text Element, items which can be set up in the Wizard will be disabled here.

4. As a shortcut to step 3, click Quick Add Wizards to select Template Wizards without going through the step above for each one.

   1. On the [Quick Pick Wizards for Template] window you will see a list of all Charting Wizards associated with this Template Element in the [Available Wizards] pane on the right. Simple double-click the Wizards you want, or, highlight each one and click Add Wizard to Template. Selected Wizards will be displayed in the pane on the left. A Text Element will be created for each Wizard

   2. If you want to do additional entry work for the Wizard, as described in Step 3 above, highlight the Wizard on the left and click Edit to display the Set Up Charting Template Text Element window, described above.

   3. If you select a Charting Wizard by mistake, highlight it in the left pane and click Delete.

   4. If you want to select all the Wizards in the Available Wizards pane, click Pick All Wizards.

   5. Use the Red X to close this window and the Rapid Charting Wizard will display.

5. To remove a Text Element, highlight it and click Delete.

6. To change a Text Element's location on the list, use the up and down arrows to move it up or down.

7. Several Charting Template Elements (PMH, ROS, and EXAM) give the user the option of checking All Normal, or an equivalent phrase. When this is done, a special action is taken instead of walking through the normal routine for that Template Element. The special action can be inserting text or running a wizard. To set up the All Normal action, click TEXT FOR ALL "Normal" tab.

   1. Select a wizard to run by clicking the magnifying glass beside All Normal Wizard.

      - OR -

   2. Enter text to be inserted in the Charting Note in the box beside Normal Text.

   

8. Select the Red X to close the window

Modifying Templates

If you want to make changes to a template, it will not cause any problems with existing visits which use that template. The template controls the collection of information, but it does not in anyway affect the information already collected on earlier visits. Changing a template will not affect charting notes generated with it prior to the change.