Wiki Dictation templates

[dgerry]

I have a provider that has this statement in his new patient dictation:


O: Healthy-appearing female/male in no acute distress. Head: Normocephalic/atraumatic. Neck: Supple. Lungs: No shortness of breath, no audible wheezes. Heart: Regular rate and rhythm. Abdomen: Benign.

He then dictates his musculoskeletal exam for the body area(s) the patient is being seen for and any related areas. My question is, in an audit would the statement above be a problem? Orthopaedic surgeon.

I really appreciate any opinions and assistance!

 

[mitchellde]

I have a problem with it and CMS will probably have a problem with it . They do not approve of using identical statements across the board

 

[dgerry]

Thank you.