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Wiki Observation e/m

I was wandering, our Surgeon's nurse (who is qualified) saw a pt. and the done the H&P (short form, hand written). All our Surgeon did was sign at the bottom. My question is does he not have to document that he approves with findings, or is it ok for just the signature? We are a Critical...
- laurabullard
- Thread
- Feb 17, 2016
- approves critical document findings signature
- Replies: 0
- Forum: Billing/Reimbursement
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Wiki coding currently undergoing chemotherapy I-10

Hello, Is there a way to document that a patient is currently undergoing chemo. for lung CA Coding ER and patient has a wound infection not related to chemo, but would like to document chemotherapy as an associated condition. Thanks!
- CarlaM1
- Thread
- Jan 5, 2016
- chemo coding document patient undergoing
- Replies: 0
- Forum: ICD-10
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Wiki Family History - they can't document

My provider keeps documenting non-contributory under family history, so does anyone have any reference material that clearly explains how they can't document this way? I can't seem to find anything, so any help would be greatly appreciated!
- TMB1965
- Thread
- Dec 31, 2015
- appreciated document family greatly history
- Replies: 2
- Forum: E/M

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