Use of note templates for documenting medical information

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

Centers for Medicare & Medicaid Services (CMS) documentation requirements prohibit the use of note templates.

CMS does not prohibit the use of note templates to assist in documentation of medical information associated with patient encounters.¹ Medical professionals may use templates in any format. Any templates used should support the collection and recording of all relevant information to ensure optimal patient care. This includes space for health care professionals to sufficiently document that criteria for medical necessity have been met.

CMS defines a template as a “tool/instrument/interface that assists in documenting a progress note.”¹ Physicians and other licensed independent providers routinely create their own and may even collaborate with other colleagues and care team members to develop effective templates.²

Various types of templates are used in practice. Some include a complete visit note and others are used for smaller portions of an encounter such as history- or exam-only templates. There are those that can be used for any patient visit and others tailored to a specific type of patient encounter such as an annual wellness visit or diabetes management. Templates used for documentation assistance include outlines or forms into which one adds gathered information, and “templated text,” such as pre-composed text that is imported into the note. Templated text should be reviewed and revised as necessary for each individual patient.

The American Medical Association recommends that if templates are used, they are reviewed and maintained regularly to reduce note bloat and time spent on unnecessary documentation.^3,4

• The CMS Electronic Medical Records Initiative Should Not Be Used To Detect Alleged Fraud by Physicians D-175.985

• CMS Manual System: Templates in Medical Review (PDF). Accessed May 2024.
• AMA STEPS Forward® Taming the EHR playbook. Accessed May 2024.
• AMA EHR Workflow Learning Series Using a Note Template module. Accessed May 2024.
• AMA STEPS Forward Write Shorter Notes Podcast episode. Accessed May 2024.
• Download this myth: Use of note templates for documenting medical information (PDF)

1. Centers for Medicare & Medicaid Services. Templates in Medical Review. CMS; 2018. Accessed May 13, 2024. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2018downloads/r833pi.pdf (PDF)
2. Rule A, Hribar MR. Frequent but fragmented: use of note templates to document outpatient visits at an academic health center. Journal of the American Medical Informatics Association: JAMIA. 2021;29(1):137-141. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8714279/
3. Jin J, Brown M, Sinsky C. Taming the EHR Playbook: Implement Effective System-Level Policies to Reduce the Burden of EHR Work. AMA STEPS Forward. American Medical Association; 2023. Accessed May 21, 2024. https://edhub.ama-assn.org/steps-forward/module/2813407
4. Genkins J, Mamlin B. Using a Note Template. AMA EHR Workflow Learning Series. American Medical Association; 2021. Accessed May 21, 2024. https://edhub.ama-assn.org/ehr-workflow-learning-series/interactive/18629449

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Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues.