decisionhealth Newsletters, Part B News - 2012 Issue 8 (August)
Template abuses: An HPI with all elements complete that says nothing
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Article Overview
This article reviews a common electronic health record template problem involving history of present illness documentation. It is aimed at physicians, coders, auditors, and compliance staff who work with evaluation and management documentation. The piece explains the broader issue of template-driven note completion, why documentation quality matters for supporting service levels, and general approaches to improving documentation specificity without relying on template fill-ins alone.
Why This Topic Matters
Template-generated notes can appear complete while still lacking the specificity needed to support appropriate evaluation and management coding. Understanding this issue helps practices reduce documentation risk and improve audit readiness.
What You Will Learn
- How electronic health record templates can create incomplete or unhelpful history documentation
- Why documentation specificity matters in evaluation and management support
- How broader documentation elements may be considered when history detail is limited
- What types of answers are considered more useful in a history of present illness record
Who Should Read This
- Physicians
- Medical coders
- Medical auditors
- Compliance staff
- Practice managers
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