Wiki exam documentation


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I have a provider that I am auditiing. The first page is where the MA would document the CC and a bunch of check boxes for the ROS. And then the 2nd page is where the dr documents his portion. On the note I have now the exam has:

Temp 98.7
well healed
full sensation
full ROM

That is all that is written. The MA documented that the pt is there for a laceration of 5DRH. I think in order for the physician to get credit for more than the vital he would need to have the part of body examined but another co-worker disagrees. Is this correct? or can I just go off the part of body the MA documented?
The cc and HPI must be documented by the provider not the MA.

No, I would not accept an exam that doesn't mention the body part examined.

Consitutional requires documentation of at least 3 vitals (temp, blood pressure,ht, wt. etc.)
dee is correct, this must be documented by the provider, the ROS can be collected by the MA but even still the provider must refer to the ROS and state that it has been reviewed and reviewed with the patient. Everything else must be performed and documented by the provider. You cannot have a shared visit with an MA. You could however have a shared encounter with a PA or NP and then it would be fine as long the provider writes his own note and references the information collected by the PA/NP.
I partially agree with Dee and Debra. Unless they actually state what they are examining I wouldn't give credit for those general statements.

The CC however depends on who the payer is. If you are dealing with WPS Medicare ancillary staff can obtain the CC, provider just needs to support it with their documentation.