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Wiki chief complaint-I have been auditing

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suzannereed

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I have been auditing an endocrinologist and for all of his established patients the chief complaint reads "Here for follow up evaluation. Endocrinologic." Is this satisfactory, or does he or his staff need to mention diabestes, thryoid, etc.? Please let me know what you think. Thanks in advance.
 
Sufficient

It's sufficient - but not optimal.

The chief complaint, technically, is what the PATIENT would say he is there for. "Follow-up" would about cover that.

However, in an ideal world, the physician would use this to give the coder/auditor some clue as to the reason for the visit. "follow-up for DM2" or "Post-op follow-up" are two VERY different reasons for a follow-up appointment.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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