Hospital Medicine Documentation Excellence Series
In this installment of our Hospital Medicine Documentation Excellence Series, Nettie McFarland, RHIT, CCS-P, CHC, shares best practices for using macros to support documentation of the Risk Component of Medical Decision Making (MDM).
Explore more from the Hospital Medicine Documentation Excellence Series:
MDM Macros for Hospital Medicine: Risk Component
Macros for Hospital Medicine: Medical Decision Making (MDM)
Macros for Hospital Medicine: COPA
Coding for Inpatient and Observation Discharge Services
5 Tips for Better Clinical Documentation in Hospital Medicine
Split/Shared Coding for Hospital Medicine Services
Transcript of Video:
Hi. My name is Nettie McFarlane.
I’m the Director of Provider Education here at Ventra Health. Today we’re going to be doing a brief presentation on macros for hospital medicine in the medical decision making, and we’re going to look at risk today.
Macros are features in electronic health records that enable the user to create shortcut commands, and that’s usually to help ease the administrative burden of the EHR systems.
An ideal way to use macros would be to meet the documentation requirements of medical decision making.
According to CMS, enough patient specific information should be documented so that it would support a medical necessity determination. And one way of doing this would be to create hard stops in the macro, which would require adding additional information.
In the medical decision making, we’ve got the complexity of problems addressed COPA, the amount and complexity of data. Both have a little mini webinar of their own. And then we have the risk of complications and or mortality of patient management, And that’s what we’re looking at today.
One of the items found under risk is social determinants of health. When a social determinant impacts the current visit, then if you document that, this can, lead to at least a moderate level of risk.
The macro could populate: “The following social determinants _____ are impacting care by______,” and both of those hard stops would be there to provide patient specific information.
Medication considered but not given. If you consider a medication and choose not to give it, for whatever reason, document that, and you get the credit of medical decision making as if you had given the medication. So you could put a macro with: “The following medication was considered but not given ______.” Best practice would be to document why the medication wasn’t given.
Drug therapy requiring intensive monitoring for toxicity is another area and risk. “The following medication _____ was monitored for toxicity, or ______ was monitored for toxicity.”
Consideration of escalation of care is another component of risk. With an inpatient visit, this could be consideration to higher units such as ICU. “Transfer to ICU was considered but ruled out due to _______.”
Decision for a DNR. So if a patient is already in the hospital and do not have a DNR in place and it is initiated during the visit, this qualifies for a high level of risk. The the macro you could use would be “After discussion with ______ DNR was initiated.” You could also, instead of the hard stop, put, checkboxes, for the various people that you might have the discussion with such as, children, spouse, caregiver.
So one final thought on macros. They should only be used when appropriate.
Adding the same information on every chart can result in concern over the integrity of the documentation. For example, not every patient is considered for escalation of care to ICU.
In summary, macros can be used to help ease that administrative burden of the documentation guidelines, and adding patient specific information can reduce payer issues while making the documentation more complete for continuity of care.
If you have any additional questions, please contact us. Thank you very much, and I hope you have a nice day.
