luvmyphx
Contributor
Hello,
We recently performed an audit with our weight loss clinic (wellness clinic). The provider goes over the lab orders from the PCP with the patient. There is not a way to attached the lab finding with the valves to the patients chart. The provider would like to document without the values. For example patient has evaluated cholesterol levels, with supervised diet blah, blah. Would this be correct documentation? Or would the provider need to state patients cholesterol level, 249, with supervised diet blah, blah. Or would this one be correct? Provider is addressing all the lab issues because they have a connection to the weight, but not treating the issues, the PCP is doing that.
We recently performed an audit with our weight loss clinic (wellness clinic). The provider goes over the lab orders from the PCP with the patient. There is not a way to attached the lab finding with the valves to the patients chart. The provider would like to document without the values. For example patient has evaluated cholesterol levels, with supervised diet blah, blah. Would this be correct documentation? Or would the provider need to state patients cholesterol level, 249, with supervised diet blah, blah. Or would this one be correct? Provider is addressing all the lab issues because they have a connection to the weight, but not treating the issues, the PCP is doing that.