decisionhealth Newsletters, Part B News - 2005 Issue 4 (April)
Views from a former CMD: Templates are a tool - tips to use them properly
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Article Overview
This article is a non-technical discussion for clinicians, coders, auditors, and compliance staff about using documentation templates appropriately in medical records. It explains why templates can be helpful for capturing routine findings and symptoms, and why they may need additional narrative detail to support evaluation and management documentation and the medical necessity of diagnostic testing. The piece focuses on general documentation quality issues, not on specific coding rules or code selections.
Why This Topic Matters
Template-based documentation can improve efficiency, but incomplete entries may leave out details needed to support the medical record. Understanding the limitations of templates helps reduce documentation gaps that can affect audit readiness, clinical communication, and support for services ordered or reported.
What You Will Learn
- How templates can help structure routine clinical documentation
- Why additional narrative may still be needed in some records
- How symptom and exam detail affects documentation completeness
- Why template checkboxes alone may be insufficient for certain diagnostic study justifications
- How to make template use more flexible without losing efficiency
Who Should Read This
- Physicians
- Clinicians
- Medical coders
- Medical billers
- Compliance professionals
- Auditors
- Practice managers
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