Best Practices When Using Documentation Templates

CMS allows providers to use documentation templates, but the resulting encounter note must be specific to the patient, date of service, and service(s) rendered. If you use (or plan to use) documentation templates in your practice, consider these basic compliance guidelines, as provided by WPS Medicare:

• Either the ancillary staff or the patient may complete the Review of Systems (ROS) and the Past Family Social History (PFSH) as part of the template, checklist, and/or electronic medical record. The provider must notate his/her review of the information. Additions to the file or confirming notations substantiate the provider’s review.
• The provider may use an ROS or PFSH from a previous encounter. The provider must notate the date of the earlier ROS or PFSH and review all elements of the previous encounter notating any changes or elements not reviewed.
• The billing provider must perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter it into the medical record with the provider only signing or acknowledging they read the notation.
• Documentation must clearly define the examination and findings to support the level of service submitted.
• A brief statement or notation of “negative” or “normal” is sufficient to document normal findings.
• The provider must document any specific and pertinent abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ system(s). A notation of “abnormal” without elaboration is insufficient documentation.
• The provider must describe any abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ(s) systems.
• Please forward a copy of abbreviations or “keys” used in the document if these are other than standard medical abbreviations.
• Signature requirements do not change with the use of templates, checklists, and/or electronic medical records. The documentation must show a legible identifier of the provider. You can find more information on the signature requirements in addition to attestation statements in the
CMS Internet-Only Manual (IOM), Publication 100-08, Chapter 3, Section 3.4.1.1.D.
• Providers should be wary of templates that have pre-printed information indicating certain “comprehensive” level services were performed. Documentation for each encounter must be specific to that encounter.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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