Vasectomy consults (and procedure) are provided on a regular basis in Family Medicine. Provider has a form which is completed (handwritten) and scanned into the EMR. HPI documents "Chief complaint: Vasectomy Consult see scanned." A/P documents "
Vasectomy requested -discussed r/b and poss AE and poss interactions. Denies ever having seizure. PMP neg. ICD-10; Z30.09. 30+ min reviewing chart, face to face, and documenting. Vasectomy Counseling Visit includes HPI, PFSH, exam and summary. Question - is the encounter as noted, referencing a document scanned into clinical section outside the encounter compliant/consistent with documentation requirements? My thought is to specify where that document lives in the EMR. Thank you!
Vasectomy requested -discussed r/b and poss AE and poss interactions. Denies ever having seizure. PMP neg. ICD-10; Z30.09. 30+ min reviewing chart, face to face, and documenting. Vasectomy Counseling Visit includes HPI, PFSH, exam and summary. Question - is the encounter as noted, referencing a document scanned into clinical section outside the encounter compliant/consistent with documentation requirements? My thought is to specify where that document lives in the EMR. Thank you!