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AprilSueMadison

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I'm trying to encourage our providers to document better. This is proving to be difficult, but I'm gaining some headway in the process.

One of our doctors uses "Pt is here for a general exam" only as the CC. Is there a better way we can expand that?

My thoughts are that the patient is here for something. Sun damaged skin, a suspicious spot, something of the sort that can be documented better. So far it's working well when the MAs fish for more information and ask better questions.

My question is what is the patient truly has no concerns except they are here for a yearly exam? How can I expand the CC in that case? I read somewhere that I should have how long it has been since the last exam, such as "Pt here for a general exam, it has been approx 2 years since the last one".

I'd truly appreciate any help on this, I feel like I'm in over my head for sure.
 
pt here for annual exam or pt here for general exam is perfectly fine in my opinion, if the pat is asymptomatic and is only here for the annual or biannual well visit then there should not be anything in the CC regarding a complaint or symptom. it is a V70.x or V20.x or V72.31 code for the dx code and a preventive E&M for non-medicare.
You should never "fish" for more information, the CC is what the patient feels they are there for, the patient made the appointment you need the reason for the appointment, not something that was fished out of them.
If they are there for a follow-up visit due to having had a procedure or previous illness such as cancer, then it should state that , .. ie. "pt here for for follow up from........"
 
Thank you for your reply!

I'm still trying to get this documentation thing down. We are having some issues with it here and I'm trying to get the doctors to first, do their own HPI instead of having an MA do it...because the doctor has to do their own. Second, cut down on what looks like copy and paste, and third, work on making sure our EHR templates create patient specific documentation.

Their documentation could be better for sure.

I've been at this job for over a year now and every few months I try to make a change for the better to ensure we are following regulations.

I can honestly say I'm in over my head and doing the best I can to make sure we are doing what we are supposed to. I'm constantly asking questions here and elsewhere to get information to back me up. The CC was the one thing I was having trouble finding anything but basic information for.

If you have any other suggestions after knowing more of the background, I'd truly appreciate it.

(ps- I tried to message you but your inbox is full Debra)
 
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