Short Answer

Templates are valuable tools for enhancing the efficiency of documentation, but it is essential to ensure that each template utilized incorporates all required elements, and efforts should always be made to customize the documentation of each patient encounter.

Why Should Documentation Be Patient-Specific?

A common mistake is not editing a template so that it is patient-specific, which results in documentation of information that is erroneous or doesn't apply to the patient. For example, when using a template for the initial history and physical, the template states the patient has a normal gait, but in reality, the patient has an antalgic gait due to pain.

What Happens When History and Physical Information Is Carried Forward?

Another common problem is carrying forward the initial history and physical to subsequent visit notes when another history and physical was not performed. By including the history and physical, you imply that you performed a history and physical on that visit. Instead, document any changes to the initial history and physical or that the history and physical are unchanged. The progress note should only include documentation of the service(s) that you provided on that visit.

Should Information That Is Not Relevant to the Visit Be Included?

Some pre-populated templates contain extraneous information that does not apply to the reason for the patient's visit or plan of treatment. For example, documentation that the patient is "well-developed, well-nourished and with good attention to hygiene and body habits" and "oriented to person, place and time" in every progress note when there is no history that the patient ever had a problem with hygiene or cognition is ill advised.

Documentation containing a large volume of information that does not relate to the specific patient or the patient's complaints is difficult to read and may prove less effective than a simple record which is clinically relevant and accurately describes the patient's condition. Furthermore, information recorded should be pertinent to the patient's visit and treatment plan; extraneous or unrelated details should be omitted from the documentation.

Why Should Notes Be Reviewed Before They Are Finalized?

Review your notes for inconsistencies prior to locking them in. For example, if the template notes state the patient does not have a fracture, but the diagnosis is documented as "fracture," does the patient have a fracture or not?

This could have implications for the patient's care and treatment and could also have a major impact on the ability to defend your actions in a malpractice situation.

Can Improper Use of Templates Create Audit or Liability Risks?

Improper or careless use of templates may lead to allegations of fraud and abuse in Medicare, Medicaid, and private insurance audits and investigations. Efforts should always be made to customize the documentation of each patient encounter.

How Often Should Documentation Templates Be Reviewed?

Templates are valuable tools for enhancing the efficiency of documentation, but it is essential to ensure that each template utilized incorporates all required elements. Sections such as patient information, history and physical examination, progress notes, wounds and lesions, and pre/intra/postoperative care detail the documentation standards for their respective areas within the medical record. In addition to adhering to these documentation guidelines, it is important to regularly review and update templates to reflect current best practices and regulatory requirements.

This ongoing process helps ensure that records remain accurate, comprehensive, and compliant with industry standards.

Key Takeaway

Templates can improve documentation efficiency, but they should always be customized to accurately reflect the individual patient encounter. Documentation should be clinically relevant, consistent, and limited to services actually performed. Regular review of templates and careful review of notes before finalization can help support accurate documentation and reduce risk.

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Disclaimer: The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change