Provider Crisis Documentation Guide

Cerner provides a variety of tools to expedite and enhance providers’ routine and urgent
documentation. During crisis situations where patient volumes may augment rapidly in any care
setting, easing the provider’s burden to document timely and efficiently should be a primary
consideration. While Cerner tool sets provide the capabilities to our client base, this guide
offers Cerner’s recommendations not only for documentation during the coronavirus disease
2019 (COVID-19) pandemic, but as a workbook to consider for future situations where
documentation elements may need to be rapidly changed.

While the recommendations and examples offered primarily relate to three venues and three
care giver roles – Inpatient, Ambulatory, and Emergency Department – the basic concepts can
be applied to any specialty, in any venue. Cerner focused on these three areas as those
perceived to have been most impacted by the COVID-19 pandemic.

Planning
As referenced above, Cerner recommends a multi-step decision process to approach the work.
Start with the Cerner Model Experience recommendations, add or subtract content as needed,
then assess the following details:
 Roles impacted by the crisis
 Venues where those roles are impacted
 Documentation elements that need to be addressed
 Note types currently available to the organization
 Clinical content to be added or deleted
 Regulatory changes impacting provider documentation

Considerations for Workflow Facilitation

 Is a new workflow MPages view needed? While not part of the current Cerner
COVID-19 Model Experience recommendations, such strategies are easily supported
by Cerner MPages configuration. Some organizations have decided to create new
MPages to give practitioners in administrative roles, or who have administrative
responsibilities, access to operational dashboards and other hospital data flows. Others
have developed clinically oriented MPages to give clinicians ready access to multiple
streams of clinical data in one place.
 How can we maximize data elements captured by other caregivers? Organizations
can use Smart Templates to pull clinical data elements charted by other caregivers
directly into their notes.
 Are new documentation templates needed, or should clients only enhance the
content within standard templates? In clinical emergencies, only a subset of clinical
data needs to be captured to move forward with care for the patient. Thus, an argument
can be made to create a crisis template that captures only critical clinical elements.
Because most of the clinical data in Model templates are automatically brought into the
note, Cerner’s COVID-19 Model Experience recommendations do not include creation
of a new note template.
  Are Quick Visit templates appropriate for crisis documentation? Cerner’s Quick
Visit templates support rapid clinical workflows where intake assessment, order entry,
documentation, and patient instructions are largely standard and predictable. Cerner
has created Quick Visit content for use in support of the COVID-19 crisis. See Cerner
COVID-19 Quick Visit templates discussed below under Ambulatory.
 Are Care Pathways appropriate for clinical decision support and to facilitate
documentation? Cerner’s Care Pathways support clinical decision making while
incorporating elements of ordering and documentation. Cerner created multiple Care
Pathways for use in support of the COVID-19 crisis. See Cerner COVID-19 Care
Pathways discussed below under Ambulatory.
 Is a unified provider position appropriate? For provision of clinical care, developing
a new provider position specifically designed for crisis workflow management should
not be necessary. If the crisis necessitates providers giving care outside of their typical
specialty, role, or venue, this should be accomplished using ViewPoints and position
selection. As indicated above, some clients have created new positions for physicians
involved in capacity management, triage, and bed flow, giving them access to the
operational tools and dashboards necessary to manage capacity issues.

Other Considerations
Do written policies and procedures need to be amended to cover alterations in
standards of documentation?

 Organizations need to carefully review changes in state and federal regulations

regarding the COVID-19 crises and other emergencies and make any necessary
changes to applicable bylaws, policies, rules, and regulations of the medical staff.
 These documents often include provisions for crises situations and should be reviewed,
updated if necessary, and used to provide the basis by which the organization is
providing care during the crises.
 Below are links to CMS and Joint Commission guidance regarding waivers, crises, and
telehealth privileges:
o CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
o Emergency Management - Requirements for Granting Privileges During a Disaster
o Emergency Management - Privileging Requirements When Providing Services via
Telehealth Links During a Disaster
Are there impacts to revenue cycle with alterations in documentation?

 Cerner has compiled a list of the necessary content packages to make terminology
available within your domains that enable adding COVID-19 codes. Updates will be
posted as new content is released. See COVID-19 Content Information for more
information.
 The World Health Organization (WHO) published guidelines on what diagnoses codes
to use for COVID-19. To allow adding COVID-19 codes in the Problem List and the HIM
 coding applications, see COVID-19: Diagnosis Documentation for the recommendations
outlined for necessary packages and configuration.
Are documentation templates needed to facilitate video and telephone visits? New note
templates should not be needed to support virtual visits. Global Auto Texts can be used to
insert the correct terminology needed to support accurate and complete documentation needed
for telehealth reimbursement and regulatory needs.

Venue and Note Types

 Inpatient-med or surg and ICU (history and physical (H&P), daily progress note, consult
note, and discharge note)
 Ambulatory (office visit and virtual visits)
 Emergency department

Specific Recommendations per Venue of Care

Inpatient
 To maintain current documentation workflow, Cerner recommends using current note
templates and pulling specific COVID-19 related information into those templates using
global Auto Texts and Smart Templates.
o A Smart Template should be created using the Bedrock Smart Template Wizard
to pull all clinical events that should be included in the note.
o Global Auto Texts should be created for HPI, ROS, and PE. The HPI Auto Text
should include the Smart Template and the relevant text.
o A single Smart Template and set of Auto Texts can be used for all note types or
you can create unique content for each note type.
o For COVID-19, Cerner recommends creating the Smart Template and Auto
Texts listed in the COVID-19: Acute Care Reference Build.
 Conversely, if organizations choose to create new note templates, Cerner recommends
naming them with a common prefix, so they sort together when searching.
o The COVID-19-specific Smart Template can be embedded directly in the note
template with this method.
o The new note template will be accessed by clicking Other Note Types at the
bottom of the Workflow view unless additional Quick Links are available or a
new COVID-19 Workflow MPages component is created.
 Medical staff can save and edit their own versions of the global Auto Texts, but Cerner
recommends using the organization approved global Auto Texts and Smart Templates.
This facilitates rapid deployment of content changes in the everchanging environment
of pandemics.
 Auto Texts and Dragon templates are great accelerators of clinical documentation.
Consider creating Dragon commands that trigger the COVID-19 Auto Texts.
  Virtual consultation Auto Text can be created to support remote ICU or specialty
consultations as necessary.

Ambulatory
During the COVID-19 pandemic, many ambulatory clinics are closed or have seen a marked
decrease in volume. Because of this, the use of telehealth has increased dramatically. Cerner
has created documentation tools to assist with these visits.

 For in-person visits, existing documentation methods can be used with the addition of
Auto Text and Smart Templates, where appropriate.
 For both telehealth and in-person visits, providers can use Quick Visit templates, which
incorporate documentation, orders, and patient instructions. Recommendations for a
COVID-19 Quick Visit template can be accessed from the Quick Visit sheet in the
COVID-19: Ambulatory Reference Build Guide. Auto Text phrases supporting this
content can also be viewed in this guide on the Quick Visits Auto Text sheet.
 Additionally, organizations can make use of Care Pathways, which guide the
practitioner through clinical decision support of a given condition. In collaboration with a
third party and Sharpe Medical Consulting, Cerner is providing COVID-19 content
specifically designed for implementation with Care Pathways and based on Centers for
Disease Control and Prevention (CDC) guidelines. These pathways address the
Telephone Triage, Occupational Health, and Treatment and Assessment workflows.
The content can be downloaded directly from Configure COVID-19 Care Pathways.
Once imported, the content can be modified to meet specific client needs.
 The Care Pathways content provided by Cerner and Sharpe Medical Consulting, will be
continuously monitored and updated, as needed. For additional information, see the
following resources:
o COVID-19 Occupational Health Care Pathway Content
o COVID-19 Phone Triage Care Pathway Content
o COVID-19 Treatment and Assessment Care Pathway Content
 As clinics return to normal functioning, follow-up visits for post-infection COVID-19
patients can be supported by normal clinic notes augmented by COVID-19 Global Auto
Text that capture the related data fields.

Emergency Department
In some areas of the country, ED volumes rapidly augmented in response to the pandemic. To
facilitate ED physician documentation, Cerner recommends using current ED note templates
and adding specific COVID-19 related information into those templates. This can be
accomplished primarily using a global Auto Text embedding COVID-19 specific Smart
Templates and text. Templated documentation ensures standardization, consistency, and
efficiency. Consider creating Dragon commands that trigger the Auto Texts as well.

 Global Auto Texts: Global Auto Texts can be created for any area in the
documentation. In these Auto Texts, one has the option to add Smart Templates. A
 Smart Template can easily be created using the Bedrock Smart Template Wizard to pull
all clinical events that should be included in the note.
 Procedure notes: Procedure notes can be augmented by using Auto Texts and Smart
Templates to ensure standardized documentation and inclusion of necessary clinical
data.
 Discharged patients who are persons under investigation: An Auto Text should be
employed to capture the understanding that the patient will be called about their results
if performed, patient education for clinical symptoms, the importance of self-quarantine,
reasons to return to the ED, acknowledgement of understanding by the patient, and
documentation of a stay at home (work) physician order.