Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix A: Electronic Note Title and Template Policy Considerations

This model policy recommends important legal and compliance considerations for healthcare organizations when establishing electronic note titles, templates, and/or prompts.

PURPOSE: To provide guidance on the development and maintenance of electronic note titles, templates, and prompts in the electronic health record (EHR). All internally-generated forms and shared templates that become part of the EHR must receive prior approval. Standardized note titles may facilitate the retrieval of specific patient information, and therefore must be standardized.

It is recommended that each facility have a committee, such as a Forms Approval Committee, that is responsible for the review and approval of note titles, templates, and prompts in the EHR. It is recommended that committee membership include the following representation:

• Health Information Management Services (HIMS)
• Information Technology (IT)
• Physician Liaison
• Quality Assurance
• Compliance
• Clinical Documentation Improvement (CDI)
• Nursing

Definitions:

Prompt: a function of a template designed to trigger the provider to provide required documentation.

Template: an EHR tool utilized for collection, presentation, and organization of clinical data elements.

Policy recommendations: It is the policy of XYZ Hospital that all notes, templates, and prompts (defined within this policy) that are maintained within or apart from the EHR be submitted and approved by the Forms Approval Committee prior to implementation. All notes, templates, and prompts must also go through an annual evaluation.

This policy includes the requirement of using a request form for note titles and templates, as well as for the template review checklist.

1. The following considerations should be applied:
   
   1. CPT, HCPCS, ICD-9-CM, or other administrative code sets should never be included in a progress note, consult text, or templates (even as display only).
   2. Refrain from including data that does not feed from the source system. For example, if vital signs need to be included in a template, do not enter a prompt for vital signs. Instead, use a data object that pulls the information from the Vital Signs Package.
   3. Enter the data and initials of the individual who built and requested the template in the notes section.
   4. Template fields must be inactivated rather than deleted.
   5. User experience must be considered when creating templates to ensure the least amount of mouse clicks or key strokes are utilized.
   6. All templates must be tested for usability as identified on the template request form.
   7. All templates must go through a minimum annual evaluation process.
   8. The committee is responsible for ensuring that it is updated annually, and oversees the ability to create, inactivate, or revise templates.
   9. Inactivated templates will be maintained by XYZ system.

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