how to document-code pepc indian health service health education program 2010
TRANSCRIPT
How to Document-Code PEPC
Indian Health Service
Health Education Program
2010
There are 2 PEPC Manuals. Both are located at www.ihs.gov
Volume I gives information on ‘how to document’
Volume II is the actual Protocols or guidelines of what to teach
Standard Education across IHS• The IHS has a system to document
Education for all I/T/U programs.
• This system is called the IHS Patient Education Protocols And Codes (or PEPC)
• All disciplines and Providers should be using the PEPC method of documentation and coding for education.
Where are the Protocols/Codes?
• The FY 2011 Patient Education Protocols and Codes can be found
at:
• www.ihs.gov
• Click on “Non-Medical Programs”• Scroll Down to the “Health Education”• Click on “National Patient Education Initiative”• Click on “Patient Education Protocols and Codes”
Look for Health Education Program
Patient Education Protocol and Code
HTN-C – This is the code used to document the education provided to the patient or family.
Protocols - Protocols are written guidelines for education.
HTN-C COMPLICATIONSOutcome: The patient will verbally
summarize the complications of uncontrolled hypertension.
Standards:
1. The patient will verbally summarize the complications of uncontrolled hypertension.
2. Explain that heart attacks may result from the heart having to work harder to pump blood through congested and hardened arteries.
3. Explain that blindness may result from injured blood vessels in the eye.
4. Explain that strokes may result from ruptures of injured blood vessels in the brain.
5. Explain that circulatory complications eventually impair the ability of the kidneys to filter out toxins.
Steps for Documenting Patient Education
1. Readiness to learn – optional2. *Disease state, illness, condition or system being addressed3. *Specific education topic4. *Level of patient/family understanding of the material5. *Time spent by the provider who did the education6. *Initials of the provider who did the education7. *Goal setting8. Comments - optional
*6 Mandatory steps 2 Optional steps
DistractionReceptiveEager to LearnPainSeverity of IllnessUnreceptiveIntoxication
DSTRRCPTEAGRPAIN SVILUNRCINTX
Example: EAGR-
The 1st Step: Determining: Does this patient want to learn?
1. Readiness to Learn – optional
Identify the patient’s readiness to learn: “Mrs. Smith: I am going to teach you about your diabetes. Are willing/ready to listen/learn?”
Reflects factors that may increase or decrease the patient’s ability to understand the patient education provided at this education encounter.
EAGR- DMExample:
1. Disease state/ Illness/ Condition
Next, you document the disease state/ illness/condition in one of three ways:
1. Write the actual disease state/illness/condition: Diabetes type 22. Write the ICD-9 code: 250.xx3. Write the mnemonic from the PEPC protocol: DM
Examples of common disease states:
CHFHTNCADLIPDMPMEYEPLFPTO
Coronary heart failureHypertensionCoronary artery diseaseDyslipidemiaDiabetesPain managementEye conditionPulmonaryFamily planningTobacco use
APCDPEQEXFUHPDPHMLAHYLMNPPROSTETX
Anatomy & PhysiologyComplicationsDisease ProcessEquipmentExerciseFollow-upHealth Promotion/Disease PreventionHome ManagementLifestyle AdaptationHygieneLiteratureMedicationNutritionPreventionProceduresSafetyTestingTreatmentExample: DM- NEAGR-
2. Education/topic modifierNext, write the topic code of what you discussed with the patient. Examples of standard topics in the IHS protocols:
Protocols – what does the word “protocol” mean?
• A protocol is a guideline• Therefore, in the Patient Education
Protocols and Codes, the “protocol” means a guideline of what to teach
• Providers should consult that PEPCs online to familiarize themselves with the PEPC protocols
• All Manuals are online; the IHS does not print the PEPC Manuals
DM-NDiabetes Mellitus Nutrition
• Example: You are going to teach about Diabetes Mellitus - Nutrition
• If you are not sure what you are supposed to teach about Diabetes Mellitus Nutrition, you should consult the PEPC Protocols Manual, Volume II
• The next slide is an example of the DM-N Protocol
DM-N (When you document “N” – this means that you have taught the Nutrition topic from
the Protocols)OUTCOME: The patient/family will understand the importance of
nutritional management in the control of blood glucose and develop a plan to meet nutritional goals.
STANDARDS:• Emphasize that nutritional management includes meal planning,
careful shopping, appropriate food preparation, and eating.• Describe healthy food preparation methods. Emphasize the
importance of appropriate serving sizes and reading food labels.• Identify techniques or strategies for eating out, social events, traditional
eating practices, and family support in managing blood sugar.• Explain that emotional eating from boredom, anger, frustration,
loneliness, and depression can interfere with blood sugar control, as appropriate. Alternative choices should be recommended.
• Discuss managing food intake with medication on sick days and with an exercise regime to prevent hypoglycemia.
• Refer to registered dietitian for MNT or other local resources as appropriate.
4. Level of understanding
Next to the topic code, Level of Understanding defines how well the patient and/or family understood the education.
G Good
F Fair
P Poor
R Refused
Gp Group Education - unable to assess individually
Example: DM - N - G- EAGR
Example: DM- N - G - 15 min.- EAGR
5.Time
Next, write down the length of Time you spent educating the patient.
Time should be documented in whole minutes.
Example: DM- N - G - 15 min. -Your initials here- EAGR
6. Taking credit
Make sure you get credit for the education you provided!
To take credit for the education, place either your provider number or your initials next to Time.
The final step is to assist the patient to change their behavior by helping the
Patient to set a goal to work on;
Help the patient by asking if they are willing to make a change?
• Suggest a plan
• Suggest a plan on how to maintain at least one _____
• Write a plan of management
• Plan to change to ______
• A plan to test _____ (blood sugar)
• Choose at least one change to follow _____
• Demonstrate ___ and state a personal plan for ____
• Identify a way to cope with ____
Example: DM - N - G - 15 min. - MW - GS: Drink H20 @ one meal EAGR-
7. Patient goals
Helping the patient to set a Goal:Goal Not Set, Goal Set, Goal Met, or Goal Not Met Uus the following codes. (Be sure to also write down the goal.)
GNS Goal Not Set
GS Goals Set
GM Goals Met
GNM Goals Not Met
Example: DM - N - G - 15 min. - MW - GS: - Drink H20 @ one meal EAGR
Comment: Drinks 3-4 regular Pepsi each day
8. Comments - optional
You can write comments (called Free Text) in the Comment section (called a field) for documenting additional information about the education encounter
Patient Education “String”
Education Code
TopicSub-Topic Provider Time
-Good-Fair-Poor-Refused-Group
Level of Understandi
ng
-Mnemonic (TO, HTN)-ICD9 Code-CPT Code
Readiness to Learn
-Receptive-Eager-Unreceptive-Distraction-Intoxication-Severity of illness
AP - Anatomy & Physiology C - Complications DP - Disease Process EQ - Equipment EX - Exercise FU - Follow-up
HM - Home Management HY - Hygiene LA - Lifestyle Adaptations L – Literature M – Medications MNT – Medical Nutrition Therapy
N - Nutrition P - Prevention PRO - Procedures S - SafetyTE - Tests TX - Treatment
YourInitials
7 min.
Goal
-Goal Not Set-Goal Set-Goal Met-Goal Not Met
DM M G Name-Time GS DM M G Name-Time GS
Disease State / Condition
You can document the disease state in one of three ways:
1) Diabetes type 2
2) ICD-9 code: 250.xx
3) DM - from the patient & family education protocols.
Common Disease States:
CHF Congestive Heart Failure
HTN Hypertension
CAD Coronary Artery Disease
LIP Dyslipidemia
DM Diabetes
PM Pain Management
EYE Eye condition
PL Pulmonary
FP Family Planning
TO Tobacco Use
Disease State / Condition
You can document the disease state in one of three ways:
1) Diabetes type 2
2) ICD-9 code: 250.xx
3) DM - from the patient & family education protocols.
Common Disease States:
CHF Congestive Heart Failure
HTN Hypertension
CAD Coronary Artery Disease
LIP Dyslipidemia
DM Diabetes
PM Pain Management
EYE Eye condition
PL Pulmonary
FP Family Planning
TO Tobacco Use
Education Topic Modifier
What you talked about. There are 17 standard topics in the IHS Protocols. These include:AP - Anatomy and Physiology
C - Complications
DP - Disease Process
EQ - Equipment
EX - Exercise
FU - Follow-up
HM - Home Management
LA - Lifestyle Adaptation
HY - Hygiene
L - Literature
M - Medication
N - Nutrition
P - Prevention
PRO - Procedures
S - Safety
TE - Testing
TX – Treatment
Level of Understanding
Defines how well the patient/family understood the education. It does not reflect on your ability to teach it!
G= good
F= fair
P= poor
R= refused
Gp= group education- unable to assess individually
Level of Understanding
Defines how well the patient/family understood the education. It does not reflect on your ability to teach it!
G= good
F= fair
P= poor
R= refused
Gp= group education- unable to assess individually
Taking Credit
Use either your provider number or your initials to take credit for the education. It may also be important to place the length of time you spent educating the patient next to your initials for certain billing purposes
Taking Credit
Use either your provider number or your initials to take credit for the education. It may also be important to place the length of time you spent educating the patient next to your initials for certain billing purposes
Patient Goals
GS = Goals set
GM = Goals met
GNM = Goals Not Met
GNS = Goal Not Set
Patient Goals
GS = Goals set
GM = Goals met
GNM = Goals Not Met
GNS = Goal Not Set
Where to Document Education?
If your site is using the PCC +
• Helps improve and simplify patient education documentation
WL LA-EX MW 15
Documenting patient
education on the paper PCC
The next slide is applicable only if your site is using the EHR =
Electronic Health Record
Documenting Educatio
n
on the EHR
Documenting in the EHR
Document Education
Pick Lists
Jones, Chuck M 12345 TO-QT-G-395-5minJones, Chuch M 12345 HF-current smokerMary Smith F 54321 HTN-EX-F-395-10minSara Thomas F 6789 CAD-N-G-678-15minJim Doby M 98765 LIP-N-G-369-10min
This form is used for This form is used for
documentingdocumenting
Health/Patient EducationHealth/Patient Education
in a group or community setting; in a group or community setting;
the form is then given to the form is then given to
Medical Records/Data Entry Medical Records/Data Entry
so that the information can beso that the information can be
entered in to the patient’s chart.entered in to the patient’s chart.
This form must be developed locally and is used for group education – not individual education – individual education is documented on the paper PCC or in the EHR
CRS Education Report• The CRS (Clinical Reporting System)
Education Report is a report that can be run at every site that provides detailed information on the education occurring at that site.
• Ask your IT staff to run this report.
• For questions on how to run the report contact Chris Lamer at: [email protected]
