If the chief complaint is pain, for example, the history of present illness might contain the onset, palliation, quality, radiation, severity or timing of the pain. For some chief complaints such as hypertension, however, finding four descriptive bits of information can be difficult. Again, auditors must give credit for a history of present illness that complies with either rule. Progress-note templates allow providers to specify which maneuvers in the physical exam they performed. While a check mark may occasionally be used, specific information can be supplied on each line of the template.
Legibility is improved, less writing is needed, and notes are better organized.
For the present, providers need to study the guidelines and improve their documentation. Showing interest in improved charting will help physicians convince HCFA to design rules that are more clinically relevant and easier to use. Resistance to understanding the guidelines will make this process more difficult. Only by being familiar with the regulations can physicians achieve the highest appropriate reimbursement. Internists, because of their broad overview of patient care, should be able to attain high-level visits.