Use of Documentation Templates in EHRs

Providers are allowed to use documentation templates per CMS guidelines; however, the encounter note must be specific for the patient, date of services, the diagnoses specific to today’s treatment plan and services rendered. You should consider the following basic compliance guidelines provided by WPS Medicare:

• Ancillary staff or the patient can complete the Review of Systems (ROS) and the Past Family Social History (PFSH) as part of the documentation checklist, template, and/or electronic medical record. The provider is required to notate they have reviewed the information. Any confirming notations or additions to the medical record substantiate the provider’s review.
• The provider can use a PFSH or ROS from a previous encounter, but the provider is required to notate the date of the earlier PFSH or ROS and review all elements of the previous encounter notating any changes or elements not reviewed with the patient.
• Only the billing provider is able to perform the History of Present Illness (HPI). The ancillary staff cannot collect this information and enter into the medical record with the provider only signing or acknowledging they read the notation.
• It is sufficient to document normal findings with a brief statement or notation of “negative” or “normal”.
• It is not sufficient to document “abnormal” without the provider documenting any specific and pertinent abnormal and relevant negative findings of the affected or symptomatic organ(s) systems or body area(s).
• Any abnormal or unexpected findings of the examination of the unaffected or asymptomatic organ(s) system or body area(s) must be described by the provider.
• Any abbreviations or keys that are utilized by the practice or providers in the documentation that are non-standard medical abbreviations should be documented and become part of the practice’s compliance plan.
• Provider signature requirements must show a legible identifier of the provider when using templates, checklists, and/or electronic medical records.
• Documentation for each patient encounter must be specific to that encounter and be able to stand alone.

Source: John Verhovshek - AAPC