Wiki In order to code

[Sarah Ann]

Question- someone comes into urgent care for shoulder pain. In the note - cc- here for shoulder pain.
The patient has a history of hyperlipidemia, htn, --no mention of the treatment in the note. However there is a drug list in the EMR- I was told that if there is a statin the hyperlipidemia is being treated. Doesn't the physician have to mention that info. in the note???

 

[medicalauditor]

Question- someone comes into urgent care for shoulder pain. In the note - cc- here for shoulder pain.
The patient has a history of hyperlipidemia, htn, --no mention of the treatment in the note. However there is a drug list in the EMR- I was told that if there is a statin the hyperlipidemia is being treated. Doesn't the physician have to mention that info. in the note???

Yes, the physician absolutely needs to document that in the chart note. Every chart note needs to have the assessment and plan clearly documented.

 

[Sarah Ann]

Yes, the physician absolutely needs to document that in the chart note. Every chart note needs to have the assessment and plan clearly documented.

Yes and I understand that! However we are being told to code all chronic conditions that are being treated. So if hyperlipidemia is on the list and a statin is on another list consider that treatment. No information in the note about it at all. Thanks

 

[medicalauditor]

Yes and I understand that! However we are being told to code all chronic conditions that are being treated. So if hyperlipidemia is on the list and a statin is on another list consider that treatment. No information in the note about it at all. Thanks

The assessment and plan (treatment) for every condition that is being treated, whether chronic or not, needs to be documented in the chart note. Other documents are supporting documents, to verify information in the chart note, if needed.