Justarose
Guest
I know I have read it but cannot find anything now that I need to back it up.
We have doctors who recently have begun to close their encounters days or weeks later - here is my problem ; a simple mistake on dr.s part but I believe these charts cannot be coded due to documentation and dos conflict.
The top of note is the ENCOUNTER Status which has the Pts info and DATE OF SERVICE say 10/1/12
Next is the PROGRESS NOTE Dr. John Smith 10/1/12 9:18 am SIGNED (this is not the encounter closed signature - that is completely different and found at the end of the note)
This is telling us that he saw the pt at 9:18 on 10/1 and below is his note on that visit ...
What is happening is he is mistakenly completing his closure then dating the PROGRESS NOTE with the same "late date" such as 10/9/12 versus what should be the dos 10/1/12
SO here is what it is looking like now ....
PROGRESS NOTE DR JOHN SMITH 10/9/12 9:18am Signed blah blah blah ...HPI,ROS,EXAM,Finding...ect....
Can someone lead me to where I can find documentation to prove this is not acceptable and a conflict - I need proof ..since the fight has begun...
thank you in advance !
We have doctors who recently have begun to close their encounters days or weeks later - here is my problem ; a simple mistake on dr.s part but I believe these charts cannot be coded due to documentation and dos conflict.
The top of note is the ENCOUNTER Status which has the Pts info and DATE OF SERVICE say 10/1/12
Next is the PROGRESS NOTE Dr. John Smith 10/1/12 9:18 am SIGNED (this is not the encounter closed signature - that is completely different and found at the end of the note)
This is telling us that he saw the pt at 9:18 on 10/1 and below is his note on that visit ...
What is happening is he is mistakenly completing his closure then dating the PROGRESS NOTE with the same "late date" such as 10/9/12 versus what should be the dos 10/1/12
SO here is what it is looking like now ....
PROGRESS NOTE DR JOHN SMITH 10/9/12 9:18am Signed blah blah blah ...HPI,ROS,EXAM,Finding...ect....
Can someone lead me to where I can find documentation to prove this is not acceptable and a conflict - I need proof ..since the fight has begun...
thank you in advance !