E/M Documentation

cgrussell

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One of my physicians has been documented his office visits with, exam "same as previous note". I believe I read somewhere that it may be appropriate to document history that way but I've never seen that for exam. He says he did it all the time at his previous hospital. Any help would be appreciated.
 

rthames052006

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One of my physicians has been documented his office visits with, exam "same as previous note". I believe I read somewhere that it may be appropriate to document history that way but I've never seen that for exam. He says he did it all the time at his previous hospital. Any help would be appreciated.
I'm not positive on this one... I do believe he would need to state the date of the last exam note, you shouldn't have to search for it... I agree with you about the history section...

One questions, is the pt being seen for the same problem is that why he says the exam is the same as last, just curious.
 

cgrussell

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This was just brought to my attention and I haven't done a lot of investigating yet, but the patient is probably being seen for the same reason. He has done this with several patients.
Thanks
 

rthames052006

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This was just brought to my attention and I haven't done a lot of investigating yet, but the patient is probably being seen for the same reason. He has done this with several patients.
Thanks
Oh, ok... but if the pt is coming back in I just believe the pt "deserves" to have another exam since it's the same problem, is the problem worsening, I'm assuming it is.

What is the complaint/problem, just seems to me like the doc should be doing an exam, if I were the pt I'd expect it to be done, now as for the ros or hpi that is fine.

Just my opinion
 

SandraKAdams

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Just because he's always done it, doesn't make it right, as your instincts have obviously told you. "Same as previous exam" infers that an exam was done this visit, but each note/visit should be able to stand on it's own. What if that note had to be defended in an appeal, or a specialist or covering physician had to look at it? Does this doctor expect every previous visit to be pulled/reviewed in order to find out what the previous exam revealed? That's unreasonable and poor documentation. It wouldn't pass an audit.

Sandy
 
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