Wiki Documentation from a form

[kathymoon]

I was reviewing one of my doctor's charts and he noted "form completed" in his progress notes. When I reviewed the form I found information on the form that was not in the progress notes. Basically history information. I think my question is simply - can the information on the form be part of the documetation for the E/M code? when it is not in the actual progress notes? Thanks.

 

[FTessaBartels]

NOT ideal reference

"Form completed" isn't an ideal reference, but if it's all done on the same date of service and the form is clearly signed/dated by the physician, then, yes, I'd count it.

A better documentation on the progress note would be: "Patient history form completed and reviewed by myself today. Please see form in chart for additional details."

It only takes a few seconds for this "better" documentation, and it helps to make the progress note "audit proof."

Hope that helps.

F Tessa Bartels, CPC, CEMC