decisionhealth Newsletters, Part B News - 2012 Issue 7 (July)
Template abuses: Avoid ‘all others negative’ when not all systems were reviewed
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Article Overview
This article discusses a documentation pitfall in electronic health record templates that can make a patient encounter appear more complete than it was. It is aimed at physicians, coders, and auditors who review office visit documentation, and it focuses on how template language, chart review, and carrier policy awareness can affect the integrity of the record and evaluation and management support.
Why This Topic Matters
Improper template use can create documentation that misstates the work performed and may affect coding, auditing, and payer review. The article is relevant to practices trying to improve EHR documentation accuracy and reduce compliance risk.
What You Will Learn
- How EHR template language can affect review-of-systems documentation
- Why documentation audits can help identify problematic template patterns
- How practices can make documentation clearer when a complete review is performed
- How partial system review should be reflected in the record
- Why payer policy awareness matters for template language
Who Should Read This
- Physicians
- Coders
- Billers
- Compliance staff
- Practice managers
- Auditors
Codes Discussed
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