Mama3beartn
New
Hello Everyone -
I have a question about the Number of Diagnoses or Management Options. My supervisor and I were doing an Audit on one of our Centers and they always seem to get high DX counts. We noticed they were counting "Breast Ca screening - negative today" as a count for DX. We felt this should be under the Data to be reviewed count since it did state in other part of dictation he reviewed it. We are trying to find fact about this. They are stating the terms in the definition, "Number of Management options that must be considered" means they can count this. I felt the term referred to the New problem: additional work- up planned etc. Does anyone have any clarification or better translation on this or if this actually what that means. Makes my brain hurt. LOL
I typed the example of the Assessment below. They counted 5 on the number of possible diag - est. problem; stable, improved.
thanks in advanced for the help, Really Really appreciate it....
GrInS
Sherry
Impression:
1. Anal Ca, NED x 5 years, expect cured.
2. Breast Ca screening, negative today.
3. Colon Ca screening.
4. GYN screening N/A status-post hysterectomy.
5. History of osteopenia and B12 deficiency.
Plan:
1. Follow up p.r.n.
2. Patient to have PCP/other providers handle annual screening.
3. Recommend she continue given excellent performance status despite age.
4. N/A.
5. Followed by Dr. ####.
I have a question about the Number of Diagnoses or Management Options. My supervisor and I were doing an Audit on one of our Centers and they always seem to get high DX counts. We noticed they were counting "Breast Ca screening - negative today" as a count for DX. We felt this should be under the Data to be reviewed count since it did state in other part of dictation he reviewed it. We are trying to find fact about this. They are stating the terms in the definition, "Number of Management options that must be considered" means they can count this. I felt the term referred to the New problem: additional work- up planned etc. Does anyone have any clarification or better translation on this or if this actually what that means. Makes my brain hurt. LOL
I typed the example of the Assessment below. They counted 5 on the number of possible diag - est. problem; stable, improved.
thanks in advanced for the help, Really Really appreciate it....
GrInS
Sherry
Impression:
1. Anal Ca, NED x 5 years, expect cured.
2. Breast Ca screening, negative today.
3. Colon Ca screening.
4. GYN screening N/A status-post hysterectomy.
5. History of osteopenia and B12 deficiency.
Plan:
1. Follow up p.r.n.
2. Patient to have PCP/other providers handle annual screening.
3. Recommend she continue given excellent performance status despite age.
4. N/A.
5. Followed by Dr. ####.