The first section of Document Skeleton creation is the Edit Template tab. This section includes settings which will define how the document behaves including its category, how it will be triggered, who has access to the document skeleton, and when it will be made available for selection.
DS Name: This is the current name of the document skeleton. As discussed previously, it is possible for it to be renamed at any time.
Category: there are 3 main categories a document skeleton can belong to, each with their own purpose. They are Documentation, Billing, and Treatment Orders.
- Documentation: includes documentation elements such as Physical Exam sets and notes.
- Billing: includes any Evaluation and Management codes, office visit codes, and CPT codes. Additionally, specific Physical Exam sets along with Symptoms and Modifiers are often included to ensure the billing requirements of a CPT code are met.
- Treatment Orders: includes Medications, Labs, Procedures, Imaging, Consolations and Referrals, and DME, as well as sets of orders for Pre Ops and Procedures.
It's worth noting that Document Skeletons can be extremely flexible in their setup and implementation, and while a Document Skeleton can contain elements from each of these categories, generally speaking it is best to create them separately so they can be selected by the Provider in pieces allowing for more flexibility while creating documentation for a specific encounter.
Clinic: select the clinics in which the document skeleton will be available.
Trigger Type: this defines how a document skeleton will trigger, or when it will be made available for a specific encounter. There are 2 trigger types available: Diagnosis and Chief Complaint. One or both of these options can be selected and, once Saved, Diagnosis and/or Chief Complaint tab(s) will be made available in the tabs section above.
- Diagnosis: When a Provider selects a ICD-10 diagnosis code in the encounter documentation all available document skeletons with a trigger type of Diagnosis with that particular ICD-10 code will be made available to the Provider to select and use. This is the most popular and most often used trigger type.
- Chief Complaint: if a document skeleton is selected to trigger off of a Chief Complaint it will become available to select and use by the Provider in the Patient Visit Summary.
Appointment Type: it is possible to further filter which document skeletons are available based on the type of appointment. Diagnostic appointment types are used for any new problems or new patients, while Follow Up document skeletons are used strictly for preexisting patient problems. Document Skeletons can also be created specifically for Procedure, Pre-Op, and Post-Op documentation sets.
Patient Type: Document skeletons can be made available for only a New or Existing patient.
Medical Specialty: it is possible to display document skeletons only for specific medical specialties. First, select the desired specialty from the dropdown menu, then click 'Add'. To add another specialty repeat the process. To remove a specialty from the list, click the 'x'.
Note: If you don't see the specialty you are looking for, it can be added in the Medical Specialty dictionary.
Provider: selecting Providers in this section will assign the document skeleton only to those listed. Select the name of the Provider you want to add to the list, then click 'Add.' Repeat as necessary.
Payer: this option allows the ability to include or exclude a specific payer or set of payers. First select whether the you want to Include or Exclude the payer. Next, search for the payer name in the search field, select the desired payer and click 'Add.' Repeat as necessary.
Note: If you don't see the desired Payer in the list, it can be added in the Payers dictionary.
Is Generic: This is used for internal purposes only during implementation. No attention here is required.
Is Valid: Is Valid is selected by default and makes the document skeleton available to be used. If a document skeleton needs to be removed from the providers list of available document skeletons, deselect this option and Save.
Once all desired settings have been input click the 'Save' button near the top right corner of the page. To return to the Document Skeleton list page click 'Cancel.'