Wiki Documentation Templates - check box

[slgarland]

One of the providers I work with is convinced having a template is the way to get the best documentation. He wants to use a check box with a list of options for ROS, HPI, the exam and even the MDM. My question is how much of your documentation is done in a "check box" format and have you rec'd any denials or audits by Medicare for submitting documentation like this?

 

[Pam Warren]

Checkbox templates are essentially what any Electronic Health Record consists of, but the software then reports this information into a readable document that's similar to a dicated note. Using templates in the paper environment is common with regards to ROS and exam, but History and decision making lend themselves much better to dictation or text. The use of checkboxes is OK when the findings are normal, but an explanation needs to be given for any abnormal findings. And there's always the same risk with templates in that the provider checks off everything, whether or not it was addressed or examined. Templates are not prohibited by CMS, they just have to be used compliantly and have to support what was billed out.