...but don't fit anywhere.
Firstly, the medical record is a legal document. It belongs to the practice/facility. However the information is the patient's property.It can be subpoenaed, looked at by auditors and involved care providers, billers and coders, the patient, anyone the patient authorizes.
Templates are very useful,but there are a few problems with them. The first is the notorious cut and paste. This will sometimes show up as suspiciously identical chart entries or procedure reports. They should not be done. When someone does this, there is a risk of differences in the encounters being missed. A coder who realities this is going on should let their supervisor know.
Another issue with templates is that providers may use them incorrectly. Using a template for one treatment when another was actually performed. It is important to read these very closely.
There are times still when paper documentation is done. If a mistake is made, the author is to draw a single line through the error, the date and initials above it. If there's room, the correct entry can be added there - or it can be listed as an addendum.
An H&P (History and Physical) must be done and in the chart within 24 hours of anesthesia/admission/registration. If an H&P was done within 30 days, it can be updated and used. Once. Always verify the dates - because mistakes happen.
CAC means computer assisted coding. This is a feature of most coding software that works through NLP (Natural Language Processing) and speeds up coding. As with everything else in coding, verify. This is only as good and up-to-date as the software developer has made it. It's rare but - mistakes happen.