Most conditions have two snippets: one that pertains to the history of present illness (HPI) or subjective part of the note, and one that pertains to the assessment and plan (A/P) part of the note (i.e ,.htn-hpi, and ,.htn#). The snippet for the A/P part usually has # as a suffix. The -hpi suffix is generally used for only short acronyms such as HTN or AK.
Some snippets have a -PE suffix for the physical exam section (i.e. acne, acne-PE and acne#).
Some conditions have up to five different templates. (i.e. ,.carpal-tunnel, ,.carpal-tunnel-PE, ,.carpal-tunnel#, ,.carpal-tunnel-inj, and ,.carpal-tunnel*). Note how the -hpi suffix was not used in this case.
Snippet suffix and prefix legend
assessment and plan
injection - procedure documentation
E/M visit codes
lab results messages
xray- or us-
imaging results messages
The main snippet you can use for physical exam is the “no-touch” snippet (everything documented can be gathered from entering the room, saying hi to the patient and shaking his or her hand.) This template covers nine organ systems or elements required to be documented for billing purposes. Try to start with the “no-touch” template and then add elements of the physical exam pertinent to the visit.
You will see multiple templates in other sections with the suffix -PE (i.e. ,.acne-PE, ,.knee-PE). Other templates (like abdomen, ent, cardiopulm) are categorized based on the organ system pertinent to the visit. When listening to the patient’s heart and lungs, use the cardiopulm template.
Some snippets are used as only documentation for billing purposes. For example, with transitional care management for hospital follow-ups (,.hospital f/u), providers must document that the patient was contacted within two business days.
The templates have concise and relevant information regarding the different conditions being documented. You should always edit the templates in order to document accurately. For some complex patient presentations, it is better to dictate or write the old-fashioned way. Finally, you should always read your notes before you sign them.
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