Before installing an electronic medical record system, naming and numbering standards for masterfile records should be created. Consistency across departments and sites not only reduces confusion and rework, but generates efficiency and quality.

First, set up cross-functional teams to establish standards. This helps buy-in and reduces re-work later. Make sure that the team addresses any files with relationships to other masterfiles, such as document flowsheets. Once the conventions are agreed upon, set up Excel files for each masterfile, and have these definitions and conventions accessible to all involved with the build.

For Epic installs:

• Be sure that systematic template numbering is carried over to groups and rows of specialized document flowsheets.

• SmartTools should include ID ranges reflecting the site, department, specialty or application rather than the system-generated IDs.

• Read suggested guidelines such as Dr. Peter Churgin's Red Book and Epic’s Model System Style Guide.

• If adding custom diagnoses for specialties, use an alpha code after the ICD code. This way, the procedure ID number will change, but the billing will continue to reflect the parent ICD code.

• If you are adding custom EAP records, the EAP naming convention should help users distinguish between orderable, performable, or chargeable procedures.

Regardless of vendor, consistent naming and numbering conventions will have far-reaching effects on optimizing performance, utilization and maintenance. Stakeholders will enjoy improved efficiency and higher satisfaction as their needs will have been addressed in this pre-planning process. Overall, the time spent developing standards and documentation tools for naming and numbering conventions will be paid back many times over as the system is implemented and used.

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