Wiki Documentation - like an addendum


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Can we tell the physician what is missing in their HPI? Like if they are not meeting all the criteria can we tell them what is missing so they can meet it? If so, how do we know that the physician performed/gathered all the information? can they add it after the fact like an addendum?
I do documentation improvement sessions with our physicians especially since ICD-10 requires a lot of specificity. We also did a couple of lunch and learns about E&M and the results from their individual documentation audits. Our physicians really appreciated it and have really improved their documentation. There are times they go back and do addendums when they (or we) realize they have left out importatnt information. Often it is just an oversite due to multiple interuptions, etc.

I have a really good rapport with my physicians and they respect me. The learning goes both ways. Especially when I started out and wanted to understand a disease process, etc., they would take the time to answer my questions.

Rhonda Crouch, CPC, CHONC
Respectively, you cannot tell a provider what is "missing" in their documentation, because you are not present during the time the service was rendered.
Provider's are allowed to add an addendum to their record, but there are specific guidelines that must be followed when reporting an addendum. Simply adding information and signing the addendum is not sufficient. The provider will have to document why the information is added, or removed.
You can explain to the provider that the 3 key components must be documented in detail in regards to the service that was rendered. If the provider feels they performed a more detailed service to a patient, and the provider REMEMBERS the details, then an addendum is allowed.