Clinical Documentation: The Rise of Templated Evaluations and AI

Time is a fleeting commodity, stretched thin between our work and personal lives. The lack of time has caused some healthcare providers to sacrifice the turnaround and quality of their documentation to focus more time on patient care. Unfortunately, documentation has become increasingly important over the last 15 years, with the influx of health insurance postpayment audits and prior authorizations. To fulfill this need, many are looking to incorporate templated documentation to improve efficiency and save time.

Templated documentation can allow providers to see and treat more patients, but depending on the type of templates used, this may come at the cost of additional claim denials and recoupments if the documentation is not sufficiently detailed. A template can provide structure and consistency, but if the information recorded lacks the specificity needed, then it can cause issues. If the template used is predominately checkboxes and includes limited narrative information about the patient, you run the risk of your documentation looking the same from patient to patient. Since all patient evaluations are unique, their documentation should also be unique. This is why subjective, objective, assessment and plan (SOAP) notes have proven effective for so many years and why so many templates follow the SOAP note format. When used correctly, they provide a claim reviewer with the exact information they need to make an appropriate claim determination.