Wiki Does every progress note stand alone

[HOWRU2DAY]

Does every progress need to stand alone ? I was taught that was the case but ,now I am being told that I can go anywhere in the patients chart to pull the information. For instance the patient is following up for an injury. The first vist is very detailed but the follow ups are not as detailed to assign the most specific ICD10 code. Can I use the details in the first note for a more specific code selection on my date of service ?

 

[TThivierge]

Progress Note Stand Alone

Hi There

Yes you can read other details in inpatient record related to current dates of inpatient coding. But that doc should give you his view on when he saw the patient related to type of inpatient CPT code billed. His progress note needs to stand alone plus give dx codes too. He must give you that..he must give you a dx code.It maybe similar to another doc patient saw the same patient same week. And ensure he signs it and dates it too. Certain inpt. CPT codes require certain guides with documentation(add on vs listing minutes in documentation like Prolonged Services).

I hope this helps you
Lady T