Close Up with Our Templates

HPI: CMS and other payers require the documentation of 4 elements to access billing codes for higher levels of care. Both level 4 and level 5 visits require this.

The 4 elements must be from the government approved list of HPI ITEMS:

  • Location
  • Quality / Character
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying Factors
  • Associated Signs and Symptoms

This works fine for pain complaints for which they were designed, but not so well for fatigue, depression, or non-specific and vague complaints often seen in an emergency department. We start with what is always applicable and allows the physician to quickly comply with the rules then add what is clinically relevant in the physicians mind.

It gets down what you need quickly so you can concentrate on patient care instead of filling out forms.

Sample: Side 1 of the Adult General Medical Template

Our forms make compliance easy and helps promote good patient care.

In addition, take note of these advantages:

  1. PMH essentials
  2. Teaching physician compliance done easy
  3. Mid-level supervision
  4. Graded findings better than circle and slash

Sample: Quick Compliant ROS

Rapid ROS with at least 10 systems should be the goal of documentation on almost every patient. This complies with the level 5 documentation requirements established by CMS for Medicare and required by many other third party payers. Documentation at this assures that when the complexity rises to that level, expectedly or not, the chart will support full level 5 coding, billing and payment. It is easy to have the chart at the bedside and just address each system and mark the results.

Use the grading system to save space and make the record clear.

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