Wiki Chart audit

[tknotts@ptchc.com]

Can someone give me their opinion on a chart note. I have ask the provider to be specific and he does not see anything wrong with his note. This is how are notes are documented.
Active problems:
CKD stage 3
DM
HTN

Chief complaint: Check up, review labs.

HPI:
pt is 76 year old female.
Had fasting blood test here on 1/7/20. Has multiple medical problems as noted above.
Last seen on 8/8/19 with exam which included annual.
Allergy list reviewed. Medication reconciliation performed.

Current Medications:

 

[thomas7331]

Are you auditing this from a coding perspective or for clinical documentation improvement? This is very minimal documentation that doesn't give a clear picture of the medical necessity for why the patient is being seen or what their clinical condition really is, and what you have here certainly doesn't support more than a 99212, and even that is questionable. But how you address this with the provider is going to depend on what you are trying to achieve - if you want your provider to be more specific, then you will also need to be more specific about where you feel there is a need for improvement.

I might suggest pulling out a copy of the 1995 Documentation Guidelines for E/M Services from CMS, linked below. The guidelines list of in a lot of detail what should be included in E/M notes - look especially at the bullet points in italics labeled with a 'DG'. There's a section at the beginning of the guidelines called 'General Principles of Medical Record Documentation' that is helpful, in addition to the guidance on what needs to be included in a Chief Complaint, HPI, etc. Pull out some sections that are relevant to what you are seeing in the reocrds and go through them with the provider. I think this would be your best starting point - the official guidelines say it all better than anyone can here in a short post.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf