maine4me
Guru
Currently, I am working with one of our general surgeons who is embarking on the adventure of documenting office services in the EMR. He has been using the EMR for a couple of months, so I am reviewing his notes to ensure that he is capturing all the necessary components.
After looking at his notes, I feel it necessary to streamline his process. Believe it or not! Let me put it this way a follow-up visit may have a note approximately 5 pages long.
Since this is general surgery there is usually a specific problem being treated. My concern is that he does a complete examination for every patient, new or established. Is there any reason that this may be a red flag to an outside auditor?
I do not want to change his clinical process, but to me it almost appears that he is trying to bump up the charge with his exam. I just would appreciate any thoughts, and advice as to how to approach this if this could be a trouble spot for him and the practice.
Thanks
After looking at his notes, I feel it necessary to streamline his process. Believe it or not! Let me put it this way a follow-up visit may have a note approximately 5 pages long.
Since this is general surgery there is usually a specific problem being treated. My concern is that he does a complete examination for every patient, new or established. Is there any reason that this may be a red flag to an outside auditor?
I do not want to change his clinical process, but to me it almost appears that he is trying to bump up the charge with his exam. I just would appreciate any thoughts, and advice as to how to approach this if this could be a trouble spot for him and the practice.
Thanks