Wiki Documentation

[slindamood]

We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?

 

[rthames052006]

We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?

I too would be leary of a check list for the entire documentation of a visit. Do they elaborate on the positive pertinent findings on exam?

can you give an example of what their a/p looks like.

 

[sbicknell]

Not using an EMR???

Unless the check-list form allowed some written notes I don't see how he would document an HPI, any positive ROS and most important his MDM (here is what I think and how I plan to treat)

ERs used to use these kind of forms but they were multi-page. Is that what he is trying to copy? I guess I would not want to go thru an audit trying to defend a 1-page check list

 

[slindamood]

documentation problem

This is an example of the a/p.:

A: Acute Diagnosis P:
1.Alzheimers 1. Advanced
2. CHF 2. Controlled
3. HTN 3. Stable

The sheet does provide some places for notes, but not a lot & they docs never really utilize it much. I am looking for some kind of black & white proof that this is not enough but I'm not having any luck.

 

[rthames052006]

This is an example of the a/p.:

A: Acute Diagnosis P:
1.Alzheimers 1. Advanced
2. CHF 2. Controlled
3. HTN 3. Stable

The sheet does provide some places for notes, but not a lot & they docs never really utilize it much. I am looking for some kind of black & white proof that this is not enough but I'm not having any luck.

I know my local carrier would accept #3. I'm a bit leary on #1 & 2. I can see where some education would be needed here. They should elaborate more