Templates for ROS and exams- please help asap : )

Hello-

I need some help kind of ASAP!! In our practice we have EMR(electronic medical records) and our Drs and NPs would like to create templates for both the ROS and Exams.

ROS example:

ROS:
General: Denies recurrent infection. Weight gain of 62lbs over the past year and a half. Increase in fatigue over the past 6-7 months. Night sweats at least 4-5 times per week that require changing the bedding.
Skin: Denies rashes, suspicious lesions or non-healing wounds.
Head: Denies changes in visual acuity, blurriness, or eye pain.
ENT: Denies hearing loss, tinnitus, hoarseness, sinusitis, or dental pain.
Neck: Denies cervical node enlargement, history of goiter or neck pain.
Cardiac: Denies chest pain, palpitations, history of murmurs or Rheumatic fever.
Respiratory: Denies SOB/DOE, productive cough, hemoptysis or Asbestos exposure.
Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation.
Genitourinary/Sexual: Denies dysuria, hematuria, polyuria, or incontinence. Denies sexual dysfunction.
Musculoskeletal: Denies musculoskeletal pain, muscle weakness or atrophy.
Vascular: Denies peripheral edema, history of abnormal clotting or bleeding tendencies.
Endocrine: Denies polydypsia/polyphagia, heat intolerance, history of diabetes. Patient states that hse is cold all the time. She was told she had a problem with her thyroid but has not been on medication for it.

If there is a problem that the patient reports, they will add it in the appropriate section- example- Patient states that hse is cold all the time. She was told she had a problem with her thyroid but has not been on medication for it

Then the nurse signs off on it and this along with PFSH is complete for the dr when he comes in and then the dr does the exam...

Example of template for exam...
Physical Findings:
Performance Status:
General: Well groomed adult in no acute distress. Weight stable
Vital Signs:
Skin: Pink, warm and dry. No skin rashes, petechiae or bruising
HEENT: Normocephalic, No alopecia, Conjunctiva pink, Oropharynx is pink, moist, without ulceration, erythema or masses. Uvula midline. Normal dentition. No frontal or maxillary tenderness, no periorbital edema, EOM’s within normal limits
Neck: Supple, trachea midline, no thyromegaly or masses, No JVD
Chest: Without retractions or use of accessory muscles, no scarring
Breasts: Symmetrical, no masses, scars, tenderness, thickening, discharge or dimpling. Nipples everted, no discharge. No erythema or rashes.
Cardiovascular: Normal rate, and rhythm. S1 S2, no S3 S4 or murmurs
Peripheral Vascular: No cyanosis or clubbing. Distal pulses intact, no lower extremity edema, erythema, cording or calf tenderness.
Respiratory: Respirations easy and even. Breath sounds clear bilaterally.
Abdomen: Bowel sounds present in 4 quadrants, no organomegaly, palpable masses, or CVA tenderness
Lymphatic: No palpable adenopathy in cervical, clavicular, epitrochclear, axillary or inguinal regions.
Genitalia: Normal distribution of pubic hair, external genitalia without lesions, swelling or masses
Rectal: Rectal sphincter control good, no hemorrhoids, fissures, skin tags.
Musculoskeletal: Spine and upper extremities symmetrical without kyphosis or lordosis. No spinal tenderness. Full range of motion in extremities. No joint deformities, swelling or tenderness. Equal strength in upper and lower extremities bilaterally.
Neurologic: Gait and balance within normal limits. No focal neurological deficits. Cranial nerves II-XII intact. DTR 2+
Psychiatric: Alert, oriented to person place and time. Responses are appropriate. Memory, judgement and attention span within normal limits. No evidence of mood disorder.

They would like to use these for normal ROS and normal Exam and if there is anything wrong with the patient, they then would add it in the appropriate section.

I have some concerns and questions about this...

Is this something that they can do legally? And are we allowed to code using the templates and to just assume that the work was really done?

If we were to be audited, would they review this differently because it is a template instead of dictation? Would we be dinged in anyway?

Is there a link anyone has to something related to this on a Medicare/CMS website for rules and regulations? I have done multiple searches and have gotten really nowhere.

I personally have issues with templates, yes they are easier for the docs, especially with the exam, how do I really know that he listened to their heart and it wasn't just copy and pasted as I did in this question?

Anything would be helpful, especially if it is something I can print off, black and white for them.

Thank for all your help : )

templates

Careful:
http://emradvice.wordpress.com/category/em/

In E/M coding, the physician must document the chief complaint, the HPI, physical and medical decision making.

templates

If you go on to Medical Economics website, Deb Grider (and another author or two) wrote a great article on this. Here's the link:

http://medicaleconomics.modernmedicine.com/memag/author/authorDetail.jsp?id=49566

Be sure they are documenting an HPI, as Nancy said. And that the ROS and HPI don't contradict each other, which can happen with new users.

Be careful about all these being high level visits, just because it was easy.

The hard part --at times_- with these EMR notes, is you can't tell why the patient was seen, and the status of their illnesses. Encourage much detail in the HPI and comments in the assessment and plan.

Just as they say...

if you did not document it then you did not do it, you must also assume that if I document it then I did it. We do the same things over and over in an exam and if I click a template and then add the unique features of the patient (mole on arm, tinea of feet, scar in RUQ) then that is what I examined!

Your templates though look way too complex- be sure that the docs examine all those elements

Templates

Thank you all so much for your help!! Great advice and the articles were great! I love this website by the way : )

Have a great weekend