What should be documented in a patient encounter note?

Document: reason for visit, relevant history, physical examination findings, clinical assessment with diagnosis, treatment plan, medications prescribed, patient education provided, and follow-up instructions. For billing purposes, documentation must support the medical decision making complexity claimed.

How do I document efficiently while supporting higher-level E/M codes?

Focus documentation on elements that support MDM complexity: clearly state problems addressed with severity, document data reviewed (labs, imaging, outside records), and articulate clinical reasoning including risk considerations. Use templates for routine elements but customize the assessment and plan for each patient.

What is the difference between new and established patient coding?

New patients (99202-99205) have not received services from the provider or same specialty in the same group within 3 years. Established patients (99211-99215) have been seen within that period. New patient codes generally have higher RVUs. Both are selected based on MDM complexity, not documentation length.

When should I use time-based billing for encounters?

Time-based billing (total time on date of encounter) is appropriate when counseling and coordination of care dominate the visit. Document total time spent including pre-visit preparation, face-to-face time, and post-visit work. Time thresholds vary by code level. This method may support higher codes for complex care coordination.

What are documentation red flags for auditors?

Red flags include: cloned notes with identical language across visits, documentation that doesn't match billing level, lack of individualized assessment/plan, missing elements required for code level, templated ROS without customization, and discrepancies between note content and diagnoses billed.

Patient Encounter Note Template - Office Visit Documentation

Patient Encounter Note Template — Office Visit Documentation

General All Specialties Updated: 11/26/2025

The Patient Encounter Note Template is a streamlined documentation tool for physicians documenting office visits, clinic appointments, and outpatient encounters. This efficient template captures essential clinical information while supporting appropriate E/M coding (99202-99215) and maintaining documentation standards. Designed for busy practices, the template balances thoroughness with efficiency, including sections for patient presentation, focused history, targeted examination, clinical assessment, and actionable treatment plan. The format works for new patient evaluations, established patient visits, acute problems, and chronic disease management. Ideal for primary care offices, specialty clinics, urgent care centers, and any outpatient setting requiring structured encounter documentation.

Patient Encounter Note

Date: [Date] Time: [Time] Patient Type: New / Established Visit Reason: [Category]

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Chief Complaint

[Primary reason for today's visit]
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History of Present Illness

Onset and duration
Location and character
Severity and progression
Aggravating/relieving factors
Associated symptoms
Previous treatment and response

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Review of Systems

Pertinent positives: [Relevant positive findings] Pertinent negatives: [Relevant negative findings]

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Past Medical/Surgical History

Active Problems: [Relevant diagnoses] Surgeries: [Relevant procedures]

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Current Medications

[Medication list with doses]
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Allergies

[Allergies with reactions] / NKDA
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Vital Signs

BP: [X/X] | HR: [X] | RR: [X] | Temp: [X]°F | SpO2: [X]% | Wt: [X]
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Physical Examination

General: [Appearance, distress level] [Relevant Systems]: [Findings]

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Assessment

1) [Primary Diagnosis] — [Status]

Clinical Reasoning: [Brief rationale]

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Plan

Treatment

[Medication changes/prescriptions]
[Referrals]

Patient Education

[Key teaching points]

Follow-up

Return: [Timeframe]
Sooner if: [Specific concerns]

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Provider: [Name, Credentials]