Making medical documentation simple and painless with template based documentation tools. Prompters help remind users about the 1997 E&M Documentation guidelines, to help insure compliance with the requirements for the highest levels of medical billing.

1. Medical Templates Making Medical Documentation Simple and Painless

3. MedicalTemplates Can Help!

7. Documentation reminders of requirements for the relevant section Link to the 1997 Guidelines for Evaluation & Management Services Separate “yes” and “no” options for documenting pertinent positive and negative responses Reset buttons

13. A Quick Review of Medical Documentation Requirements

16. The History

17. History Components and Levels New patient evaluations MUST have at least a Detailed History Comprehensive Complete Complete Extended Detailed Pertinent Extended Extended Expanded Problem Focused N/A Problem pertinent Brief Problem Focused N/A N/A Brief Type of History PFSH ROS HPI

21. The Exam

27. Medical Decision Making

28. Complexity of Medical Decision Making High High Extensive Extensive Moderate Moderate Moderate Multiple Low Low Limited Limited Straightforward Minimal Minimal or None Minimal Complexity of Decision Making Risk of Complications and/or Morbidity or Mortality Amount and/or Complexity of Data to be Reviewed Number of Diagnoses Or Management Options

29. Examples of Documentation Requirements