btadlock1
Guest
I'm reviewing a lot of charts for one provider, and I've noticed that regardless of what else is documented on the exam, these things are ALWAYS documented - the same way, every time...
Gen. AOx3
CV: RRR S1, S2
Respiratory: CTA
Abdomen: Active x4, Soft, non-tender
Extremeties, no edema.
Is this okay? Some of the notes are handwritten, and it looks like the information is filled in out of habit - it's always positioned the same way on the note, in about the same spot. I can't even be sure that the doctor actually checked it. Would this be considered cut-and-paste documentation? And if so, how is it any different than using a template instead? I've really got to get an accurate audit on this clinic, and I don't want to give them credit for something that the OIG wouldn't. This info makes the difference between having enough for a separate E/M, or not. Any help would be much appreciated!
Gen. AOx3
CV: RRR S1, S2
Respiratory: CTA
Abdomen: Active x4, Soft, non-tender
Extremeties, no edema.
Is this okay? Some of the notes are handwritten, and it looks like the information is filled in out of habit - it's always positioned the same way on the note, in about the same spot. I can't even be sure that the doctor actually checked it. Would this be considered cut-and-paste documentation? And if so, how is it any different than using a template instead? I've really got to get an accurate audit on this clinic, and I don't want to give them credit for something that the OIG wouldn't. This info makes the difference between having enough for a separate E/M, or not. Any help would be much appreciated!