Be Careful When Using Template Charts

Template (check-off) charting is useful for billing documentation. It is also frequently helpful in reminding us of important issues. However, there are several potential problems.

First, be sure to actually do everything you indicate that you did. Sometimes it is tempting to check off items that were not actually performed. Second, place your checkmarks carefully. Be sure your marks are in the correct squares. Finally, always write or dictate a summary note, except in the most routine cases (e.g., ankle sprain or sore throat). It is very difficult to defend your thought process if it is not apparent from the chart. Check marks and circles do not explain why you sent that chest pain patient home.

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