Templates to fulfill the documentation requirements
for the appropriate level of service are a common
resource. They help the physician record sufficient
documentation to support the level of medical
decision-making required. Templates provide
legibility and remind the physician to document
encounters legibly and completely. Templates may
be in an electronic format or may be in the form of
a paper chart. The template can utilize a check-box
system as long as the check-box system is uniquely
completed for each patient and abnormal findings
are described. Many Electronic Medical Record
(EMR) systems have built in templates to cross check
your work.
In the future, it may be necessary to provide
information to insurance companies for compliance
and utilization of medical resources. This
documentation may be easier to provide in an
electronic format vs. a paper format.
Counseling components:
• Diagnostic results
• Prognosis
• Risks and benefits of treatment options
• Impressions
• Instructions for management
• Importance of compliance with chosen treatment options
• Risk factor reductions
• Patient and family education
