tmorgan808
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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?
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?