How to Document-Code PEPC

1. How to Document-Code PEPC Indian Health Service Health Education Program 2010

2. 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

3. 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.

4. 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”

6. Look for Health Education Program

7. Patient Education Protocol and Code • HTN-CCOMPLICATIONS • Outcome: The patient will verbally summarize the complications of uncontrolled hypertension. • Standards: • The patient will verbally summarize the complications of uncontrolled hypertension. • Explain that heart attacks may result from the heart having to work harder to pump blood through congested and hardened arteries. • Explain that blindness may result from injured blood vessels in the eye. • Explain that strokes may result from ruptures of injured blood vessels in the brain. • Explain that circulatory complications eventually impair the ability of the kidneys to filter out toxins. HTN-C – This is the code used to document the education provided to the patient or family. Protocols - Protocols are written guidelines for education.

8. Steps for Documenting Patient Education *6 Mandatory steps 2 Optional steps • Readiness to learn – optional • *Disease state, illness, condition or system being addressed • *Specific education topic • *Level of patient/family understanding of the material • *Time spent by the provider who did the education • *Initials of the provider who did the education • *Goal setting • Comments - optional

9. 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. DSTR RCPT EAGR PAIN SVIL UNRC INTX Distraction Receptive Eager to Learn Pain Severity of Illness Unreceptive Intoxication Example: EAGR-

10. 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 2 2. Write the ICD-9 code: 250.xx 3. Write the mnemonic from the PEPC protocol: DM Examples of common disease states: Example: EAGR- DM

11. 2. Education/topic modifier Next, write the topic code of what you discussed with the patient. Examples of standard topics in the IHS protocols: Example: EAGR- DM - N

12. 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

13. 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

14. 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.

15. 4. Level of understanding Next to the topic code, Level of Understanding defines how well the patient and/or family understoodthe education. G Good F Fair P Poor R Refused GpGroup Education - unable to assess individually Example: DM - N - EAGR - G

16. 5.Time Next, write down the length of Time you spent educating the patient. Time should be documented in whole minutes. Example: - EAGR DM - N - G - 15 min.

17. 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. Example: - EAGR DM - N - G - 15 min. -Your initials here

18. 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 ____

19. 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: EAGR- DM - N - G - 15 min. - MW - GS: Drink H20 @ one meal

20. 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 EAGR Example: DM - N - G - 15 min. - MW - GS: - Drink H20 @ one meal Comment: Drinks 3-4 regular Pepsi each day

21. Readiness to Learn Level of Understanding Sub-Topic Topic Provider Time Goal Education Code Patient Education “String” -Good -Fair -Poor -Refused -Group -Mnemonic (TO, HTN) -ICD9 Code -CPT Code Your Initials 7 min. -Receptive -Eager -Unreceptive -Distraction -Intoxication -Severity of illness • Goal Not Set • Goal Set • Goal Met • Goal Not Met HM - Home Management HY - Hygiene LA - Lifestyle Adaptations L – Literature M – Medications MNT – Medical Nutrition Therapy N - Nutrition P - Prevention PRO - Procedures S - Safety TE - Tests TX - Treatment AP - Anatomy & Physiology C - Complications DP - Disease Process EQ - Equipment EX - Exercise FU - Follow-up

22. DMM G Name-TimeGS 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 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 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 Patient Goals GS = Goals set GM = Goals met GNM = Goals Not Met GNS = Goal Not Set

23. Where to Document Education?

24. If your site is using the PCC + • Helps improve and simplify patient education documentation WL LA-EX MW 15

25. Documenting patient education on the paper PCC

26. The next slide is applicable only if your site is using the EHR = Electronic Health Record

27. Documenting Education on the EHR

28. Documenting in the EHR

29. Document Education

30. Pick Lists

31. Jones, Chuck M 12345 TO-QT-G-395-5min Jones, Chuch M 12345 HF-current smoker Mary Smith F 54321 HTN-EX-F-395-10min Sara Thomas F 6789 CAD-N-G-678-15min Jim Doby M 98765 LIP-N-G-369-10min 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 This form is used for documenting Health/Patient Education in a group or community setting; the form is then given to Medical Records/Data Entry so that the information can be entered in to the patient’s chart.

32. 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: Chris.Lamer@ihs.gov

33. Questions? • Contact: Mary.Wachacha@ihs.gov or • Chris.Lamer@ihs.gov