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Documentation

S

solocoder

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springfield, MO
:confused: My documentation question is regarding 2 similar problems.
If a dr. states "no medical history on file" do I count that as a medical history??
And in his exam, if he states: Musculoskeletal: Non-contributory, Dematological: Non-contributory, do I count those systems toward the exam??
 
rashleygaeke said:
:confused: My documentation question is regarding 2 similar problems.
If a dr. states "no medical history on file" do I count that as a medical history??
And in his exam, if he states: Musculoskeletal: Non-contributory, Dematological: Non-contributory, do I count those systems toward the exam??
Click to expand...

Personally speaking, I would not count "no medical history on file" unless there was sufficient amount of documentation as to why...(lack of family, no previous records for review, etc)

I certainly would not credit "Musculoskeletal: Non-contributory, Dematological: Non-contributory" towards the exam. These statements tell me nothing. As far as I'm concerned, those systems weren't examined.
 
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