I have a question about auditing a physicians documentation. Some physicians document using a template and others only dictate a letter to the referring physician for any type of office visit. I am not sure if this type of documentation is correct and will cover all the key points needed to code an E/M code. The letter does not have a Chief Complaint, however it is documented in writting on a separate form. The letter does not refer to any ROS. The HPI, PSFH, and exam is documented. Please let me know any thoughts on using referral letters as office documentation.