Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix C: Checklist for Template Review

This checklist may be used by the requestor prior to submission of the template and by health information management services (HIMS) or the informatics department prior to the release of the template for testing. It could also be an electronic document used in conjunction with the request form.

Is the template a duplicate or similar to another template presently in usage?

SPELLING:

Correct use of abbreviations?

Abbreviation key included in the template or is the abbreviation included in approved abbreviation list?

Contains an item from the “Do Not Use” abbreviations list?

Correct spelling of acronyms?

FORMAT:

Capitalize headers with a colon at the end of the text?

Capitalize first letter of each item in a pick list?

Are there indentations of two spaces when appropriate?

Is the punctuation consistent and correct?

Will the documentation in the template follow a logical flow?

GRAMMAR:

Is the correct tense maintained throughout template?

Review for the singular use of a consistent term (i.e. patient; client; he/she; his/her).

Do not use they or their when referring to one patient.

Correct use of gender if the note is intended to be gender specific.

GENERAL REQUIREMENTS:

Default values may cause erroneous information in documentation and should not be included.

Indicate required fields by using (R).

Yes and no answer fields may require additional space to elaborate the answer.

If using a field entitled “Other”, do not include the term “other” in the note.

Does the intent of the request meet or enhance documentation and accreditation requirements?

REVIEW OF NOTE TITLES:

Is the submission a duplicate or similar to another note title presently being used?

SPELLING:

Correct spelling of terms?

Discourage the use of abbreviations?

FORMAT:

Does the note title follow the established hierarchy or mapping mechanism?

GENERAL REQUIREMENTS:

Does the note title correctly reflect the contents of the template?

Is the note title intended to trigger an alert to the provider
(i.e. Advance directive; Possible patient disruptive behavior)?

Return to practice brief.