Clip And Save: Use This Simple Tool to Ensure You Cover Every System Possible

Article Overview

This short article focuses on documentation support for evaluation and management visits, with emphasis on using a simple template to help capture review-of-systems information consistently. It is relevant to physicians, coders, and billing staff who want to understand general charting practices that support E/M level selection and documentation review. The article also notes considerations around patient-completed templates and the need for patient-specific documentation review.