Myth or fact? CMS says note templates are a no-go

In an era of unending clerical work, using note templates to complete documentation can be a great way for a physician to cut down on the busywork and free up more time to spend caring for patients. 

But some physician practice and health care organization leaders believe that documentation requirements from the Centers for Medicare & Medicaid Services (CMS) bar physicians from using note templates. An AMA expert review, however, shows the government has no rules that stop physicians from using templates to help them document medical information tied to patient encounters. 

The AMA is spreading that message as part of a series of “Debunking Regulatory Myths” articles that provide clarification to physicians and their care teams in an effort to reduce the administrative and other burdens that divert doctors’ attention from the delivery of patient care. 

From AI implementation to EHR adoption and usability, the AMA is making technology work for physicians, ensuring that it is an asset to doctors—not a burden. 

CMS says a template is a “tool/instrument/interface that assists in documenting a progress note.” 

Physicians and other medical professionals are allowed to use any format of template that they would like. Physicians can create their own template or collaborate with colleagues and care team members to develop templates that work for their practice needs. 

Templates should support collecting and recording all the information needed to ensure optimal patient care, including room to properly document that medical necessity criteria were met. A template can, for example, be a document that includes outlines that allow a physician to add the gathered information or it can involve “templated text” that is precomposed text that can be imported into the note. Experts note, however, that when physicians import templated text, they should review it and revise it as needed for each individual patient.  

Some other examples of templates that physician practices use include: 

• A complete visit note. 
• A visit note that covers just a portion of the encounter, such as a history-only or exam-only template. 
• A note tailored for any patient visit. 
• A note tailored to a specific type of patient encounter. For example, one note may be used for an annual wellness visit, while another note is used for a visit involving diabetes management.  

The AMA recommends that practices review and regularly maintain templates so that they reduce note bloat and the time that physicians spend on unnecessary documentation.  

The AMA has a number of resources that can help your practice optimize using template in your practice, including resources to help avoid note bloat: 

• The AMA STEPS Forward^® “Taming the EHR Playbook” helps physician practices develop a comprehensive plan that minimizes redundant tasks, streamlines workflow and enhances electronic health record proficiency to reduce the EHR burden on clinicians and enhance overall productivity and well-being. 
• The AMA EHR Workflow Learning Series “Using a Note Template” module helps physicians understand, among other things, how a note template can guide workflow and recognize risks associated with using a note template. 
• The “AMA STEPS Forward Podcast” episode, “Write Shorter Notes,” features expert insights from internists and clinical informaticists detailing how physicians can spend less time writing notes by implementing a standardized progress note template. 

Learn more with the “AMA Debunking Medical Practice Regulatory Myths Learning Series,” which is available on AMA Ed Hub™. For each topic completed, a physician can receive CME for a maximum of 0.25 AMA PRA Category 1 Credit™. 

Physicians who would like clarification about a potentially misinterpreted rule or regulation that has burdened them or their care team are encouraged to contact the AMA’s experts, who will research the matter. If the concern turns out to be a bona fide regulation that unnecessarily diverts physicians’ time and focus away from their patients, the AMA can advocate for regulatory change. 

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