Following HCFA guidelines
Templates can help physicians comply with HCFA guidelines. Oyler says, "Most physicians focus more on their clinical examination than their writing skills, and thankfully so. Many of the guidelines are so tough to remember that they are missed. In other words, if something isn’t documented, then it wasn’t done." As a result, reimbursement is decreased, he says.
• Possible future computerized analysis of patient management.
Vendors are currently beta testing computerized template systems that are designed to analyze data, in addition to documentation. "Each checkbox contains data that can be analyzed on a database," Graff says. "After documentation is completed, physicians can get an analysis of what is the correct code and [evaluation and management] level of service for billing. It also gives the physician suggestions on diagnosis and management issues."
1. Marill KA, Gauharou ES, Nelson BK, et al. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med 1999; 33:500-509.