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Linda Collins Blogger

Using Templates for Medical Documentation

Posted by Linda Collins | May 02, 2019

By now, we all know and live by the documentation guidelines outlined in the Medicare Supplier Manual, Chapter 3: "the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type of items ordered."

But how many of us take the easy route and use checklists or templates? Be aware that, according to CMS guidelines: templates do not qualify as adequate Medicare documentation and are subject to claim denials.

The Program Integrity Manual,, Progress Notes and Forms provides further information:

"Some templates provide limited options and/or space for the collection of information such as by using "check boxes," predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met."

What does all this Medicare jargon mean for you?

If you are using a checklist or template with limited space to provide customized information about a specific patient, you run the risk of having your claim denied for lack of documentation. Simply checking off various modifications, adjustments or measurements may not qualify as adequate documentation.

It goes without saying, in light of these requirements, that manufacturer-created and branded templates - for example, templates with a manufacturer's logo across the top - do not satisfy Medicare's documentation requirements. While these templates may be helpful in terms of identifying appropriate data points you may wish to capture in your records, they're not considered part of the official medical record by Medicare. If you rely on a specific manufacturer-created and branded template as the sole basis for claim approval, chances are your claim will get denied.

Check your documentation procedures and be sure to individually record information for each patient. In this case, trying to save time by using a template may be costly.

Read more about templates

Go to Section Progress Notes and Templates

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