Advanced Search

Eli's Rehab Report

Set Up a Template for Time Guidelines

Published on Fri Aug 01, 2003

If you are still unsure about whether your physician's documentation supports selecting your E/M level based on the amount of time he counsels the patient, consider creating a "stamp" for your medical charts. 


Many practices find it easier to meet documentation requirements if the physicians have a rubber-stamp template to guide them. Remember, however, that the information on each stamp must be unique to the patient's symptoms and the reasons you counseled him or her.  You may want to include the following information when designing your stamp, which we have placed in a clip-out form that you can use as a guide:

  • Was 50 percent or more of this visit spent on counseling and/or coordination of care?  

    ______yes  ______no

     

  • Total time of visit: ___________________

     

  • Time spent on history, exam, MDM (total time or each indicated separately):

    _____________________________________

     

  • Time spent counseling/coordinating care:

    _____________________________________

     

  • Describe content of counseling and/or coordination of care:

    _________________________________________

    _____________________________________________

    _____________________________________________

    _____________________________________________

    _____________________________________________

    _____________________________________________

    _____________________________________________

    • Other Articles in this issue of

    Eli's Rehab Report

    View All