As technology is integrated into patient care workflows, as care is increasingly delivered in teams and as patient engagement grows, it is crucial that documentation requirements are consistent with best practice.

Centers for Medicare & Medicaid Services (CMS) documentation guidelines for Current Procedural Terminology® evaluation and management (E/M) coding were last updated in 1997, when most medical encounter information was documented on paper. Since that time, more than $35 billion has been spent as part of the American Recovery and Reinvestment Act to move 20% of the world’s largest gross domestic product (health care) from paper to electronic documentation. As a result, requirements regarding the authorship of information recorded in the paper chart are incongruent with how certified electronic health record (EHR) workflows have been designed and implemented in ambulatory practice.

The 1995 and 1997 CMS guidelines for E/M documentation ( state that ancillary staff may record...

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