Optimizing knee arthroscopy documentation using a new template

Al-Dadah, Khalid; Evans, Owain; Ali, Fazal

doi:10.12968/hmed.2014.75.4.227

Cited by 4 publications

(2 citation statements)

References 4 publications

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“…These discrepancies result from incomplete clinical documentation which results in inadequate medical reimbursements ( 3 ). Previous studies have demonstrated that electronic medical record template use improves accuracy and completeness of both operative and clinical notes in orthopedic surgery, contributing to ease in interdisciplinary communication ( 4 - 6 ). Discrepancies in documentation of outpatient clinic visits could potentially result in inappropriate reimbursement.…”

Section: Introductionmentioning

confidence: 99%

Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template

Yen¹,

Oladeji²,

Moon³

et al. 2023

J Spine Surg

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Background In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to assess differences in re-imbursement between templated and non-templated outpatient documentation for patients who eventually underwent single level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) both before and after the E&M billing changes were implemented in 2021. Methods Data was collected from three spine surgeons on 41 patients who underwent a single level lumbar microdiscectomy at a tertiary care center from July 2018 to June 2019 and 35 patients seen by four spine surgeons from January through December of 2021 given the new E&M billing changes. ACDF data was collected for 52 patients between 2018 and 2019 for three spine surgeons and 30 patients from January through December of 2021 from four spine surgeons. Billing level was decided by independent coders for preoperative visits. Results During the study period from 2018–2019 for lumbar microdiscectomy, each surgeon averaged about 14 patients. Results showed variability of billing level between the three spine surgeons (surgeon 1, 3.2±0.4; surgeon 2, 3.5±0.6; and surgeon 3, 2.9±0.8). Interestingly, even after the implementation of the 2021 E&M billing changes, there was a statistically significant increased level of billing for templated notes for lumbar microdiscectomy (P=0.013). However, this did not translate to the clinic visits for patients who underwent ACDF in 2021. When data was aggregated for all the patients from 2021 who either underwent lumbar microdiscectomy or ACDF, using a template still resulted in a statistically significant higher level of billing (P<0.05). Conclusions Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities.

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Section: Introductionmentioning

confidence: 99%

Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template

Yen¹,

Oladeji²,

Moon³

et al. 2023

J Spine Surg

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“…Previously published data has suggested that the use of a preprinted template can significantly improve the quality of documentation. [ 2 ]…”

Section: Introductionmentioning

confidence: 99%

Improving Documentation and Communication Using Operative Note Proformas

Mahapatra

Ieong

2016

BMJ Qual Improv Report

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Accurate and detailed documentation of surgical procedures is part of good clinical practice, set out by the General Medical Council (GMC).Knee arthroscopy often involves large data sets which require accurate documentation for future assessment and management. This study assesses the quality of documentation of knee arthroscopy, followed by an evaluation of the implementation of a novel operative proforma.A review of 30 consecutive knee arthroscopy operation notes were analysed for missing information, set against a standardised 30 point criteria. An operation proforma was then introduced, and a further 30 consecutive knee arthroscopy operation notes were analysed. We evaluated allied health professional satisfaction with a Likert point scale survey of 21 allied healthcare professionals (recovery and ward nurses, and physiotherapists) following introduction of the proforma. The mean number of missing items on a 30 point scale was 8.8 (range 0 to 23). Examination under anaesthesia was missed in 43% of cases, tourniquet time in 37% of cases, and wear results in 17% of cases.Following introduction of the proforma, the mean number of missing items was 1.1 (range 0 to 24; p <0.001). This rose to 3.8 after one year (p <0.001) before improvement to 0.7 (p <0.01) with a new and improved proforma. Eighty percent strongly agreed the operation note was clearer, 90% strongly agreed it was more legible, 90% strongly agreed it was more understandable, 50% strongly agreed there was more information recorded, and 100% strongly agreed on the proforma having been improved.Knee arthroscopy is a common procedure with large data sets, which can often be missed or incomplete. A standardised proforma results in a statistically significant improvement in documentation and reduces the incidence of missing information. They are subjectively clearer, more legible, and generally better compared with handwritten notes. This study demonstrates the improvements in healthcare documentation, both clinically and legally, following introduction of a simple proforma. This concept should be applicable to different specialities and procedures in healthcare. ProblemThe documentation of knee arthroscopy results and intraoperative findings was generally poor in our institution, a busy urban district general hospital. The problem is frequently apparent in outpatient follow up clinics, when it can be difficult to ascertain all of the intraoperative findings, and this can make ongoing management decisions difficult. Secondarily, poor quality documentation is a significant barrier to allied health professionals being able to provide the appropriate postoperative treatment, especially if key postoperative instructions are not included in the operation note.

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An Opportunity in Op-Notes

Rudra

Kieffer

Briffa

et al. 2015

Journal of Perioperative Practice

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Operative notes in surgical practice are a vital source of information and communication between healthcare professionals as well as being a legal document. Errors and omissions can have serious effects on patient care and lead to confusion. We audited our compliance within trauma and orthopaedics at a busy district general hospital in South East England with the standard set by the Royal College of Surgeons (England) before and after the introduction of an operation note template. We achieved significant improvements in compliance across almost all of the standard's domains and recommend widespread implementation of similar templates nationally.

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Optimizing knee arthroscopy documentation using a new template

Cited by 4 publications

References 4 publications

Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template

Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template

Improving Documentation and Communication Using Operative Note Proformas

An Opportunity in Op-Notes

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