Overlooking to regularly review and update all of your documentation templates

The 4^th common mistake occurs when your documentation templates are no longer capturing all services appropriately.

First of all, the templates should capture quality patient care. Secondly, the templates should capture appropriate documentation for the services provided.

Many templates are based on the presenting complaint

This type of structure is used very frequently by an Emergency Department. Any type of templates used by a physician should be geared to capture:

1. the history
2. exam
3. and medical decision making

They should also capture any nurses notes utilized during the patient visit.

If creating your own internal templates and forms, the layout should be designed to assist staff with capturing their services performed.

10 Common Mistakes Index