Wiki Contradictory physician progress notes

[mamoosman]

I am trying to locate information stating whether or not you can code or take codes from a physicians progress note that contradicts itself. Example: in ROS physician document no depression. In subjective the physician documents "patient has depression" in assessment the physician documents "major depression disorder". Can this note be used for coding purposes? THX

 

[LLovett]

In your example it is probably ok. Remember the history piece is subjective, so that is what the patient says is going on that day. You can have a chronic issue such as depression that is under control so there are no symptoms at the time of visit which leads to a negative response in ROS.

Most issues with conflicting information start when the provider is contradicting themselves. This is generally the results of auto fill features or copy/paste options in the EMR. An example would be both positive and negative responses for the same thing in the same note, or negative findings in exam and then assessing some new problem that should have had a positive finding on exam.

Hope that helps,

Laura, CPC, CPMA, CEMC

 

[MnTwins29]

Piggybacking on what Laura said, it is also possible to get contradicting information after the exam is done. When the patient filled out the questionairre or was asked about hypertension, she might have said it is fine, no problems. Then the vitals are taken and the BP is through the roof. MD notes this, orders tests and work ups, etc and notes dx of hypertension. Here the ROS and final dx differ - and it is perfectly acceptable as the MD based his/her dx on objective data.