kewing
Networker
Hi all.
I have not been able to find guidelines/regs on this. I hope someone can give me some direction.
With EHR it is so easy for info to be pulled into a note, but there is not always evidence that the provider reviews this info or that it is even pertinent to the current patient visit. In order to choose the level of service, I have been giving credit to the provider for any documentation that is found within the note and above the signature. If reference is made to a separate document (e.g. lab results, xray report) within the note, credit is also given for that, even if the actual report is not copied into the body of the note.
We have one provider who documents "patient instructions" as a separate, signed note, but doesn't always make reference to the separate note in the primary encounter note. This almost always contains elements of his medical decision making. I would like to treat this as an "addendum", but I'm not sure this is appropriate because, looking at the primary encounter note, there is not always an indication that these "patient instructions" exist.
Does anyone have any references relating to this very gray area in EHR documentation? Or can anyone throw out some things to consider when developing a practice policy relating to the inclusion/exclusion of this info when determining e/m levels?
I know this is somewhat vague and most likely a bit confusing, but if there are thoughts out there I would appreciate reading them.
Thanks so much.
Karen
I have not been able to find guidelines/regs on this. I hope someone can give me some direction.
With EHR it is so easy for info to be pulled into a note, but there is not always evidence that the provider reviews this info or that it is even pertinent to the current patient visit. In order to choose the level of service, I have been giving credit to the provider for any documentation that is found within the note and above the signature. If reference is made to a separate document (e.g. lab results, xray report) within the note, credit is also given for that, even if the actual report is not copied into the body of the note.
We have one provider who documents "patient instructions" as a separate, signed note, but doesn't always make reference to the separate note in the primary encounter note. This almost always contains elements of his medical decision making. I would like to treat this as an "addendum", but I'm not sure this is appropriate because, looking at the primary encounter note, there is not always an indication that these "patient instructions" exist.
Does anyone have any references relating to this very gray area in EHR documentation? Or can anyone throw out some things to consider when developing a practice policy relating to the inclusion/exclusion of this info when determining e/m levels?
I know this is somewhat vague and most likely a bit confusing, but if there are thoughts out there I would appreciate reading them.
Thanks so much.
Karen