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MedicalTemplates Making Medical Documentation Simple and Painless Problem A familiar lament . . . “No matter how much I write in my history and physical exam note, I never seem to document enough to substantiate a high level encounter!” Medical documentation is not about HOW MUCH you write! It is about WHAT you write! MedicalTemplatesCan Help! What are MedicalTemplates? Standardized patient encounter forms using Adobe PDF Technology Use as a paper form OR Complete form electronically MedicalTemplates Features Documentation prompters HCFA 1997 documentation guidelines Quality reminders Medicare PQRI Checkboxes Save time Save energy Fillable Text Boxes Easy to use Save time Save energy Time saved is Money earned! The New Ambulatory Evaluation Template from MedicalTemplates Still has easy to use check boxes and fillable text boxes! Now with new features ROS with separate “yes” and “no” buttons for ease of documenting “pertinent positive and negative” findings “Reset” button for each section of ROS Built in reminders of documentation guidelines for sections of the history and physical exam Link button for 1997 Guidelines for Evaluation Management Services 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 Many Physicians Under Code! Most healthcare providers do more work than their documentation supports! And, as the saying goes, if it isn’t documented, it didn’t happen! How Much Is At Stake? Fact 33-52% of patient encounters are UNDER coded (JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”) Differences in Medicare reimbursement 99214 - 99215 = $30 99214 - 99213 = $30 If you see 30 patients per day you may lose $300 or more per day! [33%(30 patients/day) x $30/patient = $300/day] Working 5 days/week for 50 weeks, that is a poten