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Checklists: the good, the bad and the in-between
The benefits and pitfalls of templates

Keywords: Checklists: the good, the bad and the in-between (web title)


by David Frenz, MD, and Sue A. Lewis, RN, CPC, PCS



Published in the July 2011 issue of Today's Hospitalist

ALTHOUGH MOST PHYSICIANS are pretty bright, they're not super-human. Cognitive biases, distractions, stress and fatigue can lead to uneven clinical performance and outright errors. One way to try to avoid these is by using checklists and templates, which can hard wire clinical decision-making and critical processes.

But with all their promise, checklists and templates present certain perils. In this month's column, we take a look at both the pros and cons of using them.

The good (Dave)
For several years, I've used clinical templates for all my en- counters. They provide quicker, better documentation and
While templates can cut your dictation in half, they may also tempt you to review unrelated systems.

keep me on task if my mind starts to flag.

A lot of our documentation is very repetitive. We could probably dictate our standard physical exam in our sleep—"pupils equal, round, reactive to light"—and all the rest. Clinical templates dramatically reduce dictation volume, particularly for normal findings. I dictate about 50,000 lines per year, and I'd do double, maybe even triple, that amount without templates. At 12 cents a line, the hospital would need to absorb at least another $6,000 in transcription costs—and that's just for one provider.

I use templates at the bedside for my review of systems and physical exam. That ensures a consistent approach, even if I'm distracted or tired. Although I can always skip items that aren't relevant, I at least have to think about them. This helps me avoid the inevitable voltage drop between the patient and the chart, those data that I immediately forget or don't document because I'm in a hurry. Templates also prevent mix-ups: "Did this patient complain of headache, or was that someone else I saw today?"

And while your penmanship may be great, mine is abominable. The Centers for Medicare and Medicaid Services (CMS) and other payers require documentation that's legible. If an auditor can't read your notes, you won't get paid. Templates dramatically reduce the risk of that scribble penalty. Although I add handwritten clarifications to my tem- plates, they represent a minority of the overall progress note.

Finally, checklists and templates can offer huge benefits to patients. Atul Gawande, MD, the boy genius at The New Yorker, explored this in a column that he later expanded into a book. His point: Checklists make air travel exceedingly safe and can dramatically improve clinical outcomes.

Surprisingly, it's the really mundane stuff, so mundane that it's almost insulting, that needs to appear on checklists. A prime example: hand- washing and other standard precautions when placing central lines. When 100 ICUs in Michigan implemented a simple, five-item checklist, they collectively saved $175 million and more than 1,500 lives in just 18 months. That's something to think about if "cookbook medicine" generally rubs you the wrong way.

The bad (Sue)
I'll get it right out there: I'm not a fan of checklists or templates. They may offer certain advantages, but they also pack a lot of pitfalls, clinical and otherwise.

While templates save time, they often offer little clinical specificity. You know the typical format: body areas and organ systems in one column, boxes with "normal" or "abnormal" in another.

Consider the check mark in the "normal" box for "eyes." What does it mean? About all you can reliably conclude is that the patient has eyes; what was normal about them is anyone's guess. One could speculate about pupils, conjunctiva, extra ocular movements, retinal vasculature, lid and lashes—but only the person who checked the box really knows. The check box is a black box.

Then there's the vertical slash connecting all the boxes in the "normal" column. The patient is sick enough to need surgery or require hospital-based care—but by all accounts is OK. Why she wasn't discharged on the spot is a mystery.

Some templates skip the boxes and provide blank lines or fields for clinicians to populate. Although this is promising, providers too often write WNL, which apparently means "within normal limits." When you look at these documents, however, one could just as easily conclude "we never looked."

Templates can cause major coding and compliance problems. Although providers understand that labs and imaging studies require medical necessity, they often forget that the same is true for the history and physical and exam.

With templates built into electronic medical records, physicians are tempted to review unrelated body areas or organ systems, falling victim to "terminal templatitis." Reviewing or examining unnecessary systems and body areas is a big no-no, especially if it translates into charges for a higher level of service. Eye and ear examination for a patient with diverticulitis? Bit of a stretch. Looking for jaundice or JVD in an otherwise healthy patient with an ankle fracture? Give me a break.

Finally, templates may increase your medicolegal risk. In the event of a malpractice suit, you'll need detailed, patient-specific documentation in the medical record to refute allegations of negligent care. Little checkmarks and scribbles on a preprinted form or computer template may not help you when you need it the most.

The in-between
Like most things in life, there is a middle way. If you are going to use a template or checklist, consider working with your coding staff or compliance department.

They can help you develop a product that will meet current CMS/AMA documentation guidelines for evaluation and management services and support medical necessity, while still providing clinical efficiency.

Things to include are questions about the presence or absence of specific symptoms, rather than a single checkbox for an entire organ system. (See "Clinical templates: the bad and the better.") Consider treating clinical data as continuous variables rather than stark normal/abnormal categories. And be sure to include generous white space or free text fields for additional notes and comments.

David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at dafrenz@healtheast.org. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.


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