I have a specialist that under the HPI note section of the patients record on our EMR "CT scan shows no inflammatory process or mass, also no hernia. The Left-sided tenderness is significantly decreased. Exam is unremarkable. No evidence of abdominal surgical disease at this point. RTC prn." There is nothing under the exam part or ROS. I told him it was not billable and that he needed to enter it correctly. He is livid and now my boss wants something in writing stating that the HPI and exam are not interchangable. I know they are not but I can't find it in writing. Anyone know where I can get this?
We use an EMR and his statement is under the HPI heading not under an exam.When the record is generated the statement prints under CC/HPI notes.
We use an EMR and his statement is under the HPI heading not under an exam.When the record is generated the statement prints under CC/HPI notes.
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