Licenses for our medical documentation templates start at $99 for a single user. Volume discounts are available.
When completed, and in conjunction with a supporting level of medical decision making, this medical documentation template meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.
What are sleep disorders?
Sleep disorders include obstructive sleep apnea, narcolepsy, restless leg syndrome, insomnia, night terrors and others. The National Center on Sleep Disorders Research (NCSDR) estimates that 42 million Americans suffer from a chronic sleep disorder. Sleep disorders are associated with chronic sleep deprivation, elevated blood pressure, cardiovascular disease, pulmonary hypertension, cognitive dysfunction, erectile dysfunction, chronic fatigue, and other medical conditions that result in $15.9 billion in health care costs annually. Sleep disorders can have a detrimental influence in the workplace and school performance, and people who are chronically sleep deprived due to sleep disorders are at increased risk of auto accidents.
The Sleep Disorder Evaluation medical documentation template has prompters for the sleep history, medical history, medication use that affects sleep architecture, drug use history, auto accident history, physical examination, and testing options. This assists physicians in efficiently documenting a thorough history.
What needs to be documented for E&M services?
The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record. Documentation Components from the 1997 Guidelines: Medical History
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Physical Exam Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality
How can I use this medical documentation template to improve medical billing?
Using this documentation template will give you the confidence to bill at the highest level that is appropriate for the medical service you provided. This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk. Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010].
References for this Sleep Disorder medical documentation template
- HGSA Documentation worksheet
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services
Important note about medical decision making
Health care providers in Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service must used the method developed by Trailblazer Health, the local Medicare Carrier, to determine the complexity of Medical Decision Making.
Requirements to use the Sleep Disorder medical documentation template
This medical documentation template is in the Adobe PDF format, which requires the free Adobe Reader to function. With Adobe Reader, these templates can be filled out and printed as many times as you need.