Chapman86
Contributor
I am very new to OBGYN and trying to audit the OBGYN dept as a whole has me asking more questions before I can even begin.
Our OBGYN dept has asked me to do an in-depth audit of their department... including more than what I typically audit; office visits, hospital services, OB triage, ultrasounds, Deliveries, surgeries, global OB care...
My question is what is required as far as documentation for the OB global package? Do we need a traditional office visit note for each time the patient is seen or is a prenatal flowsheet(ACOG) acceptable? I understand we do not bill each time the patient is seen but wouldn't a traditional note(complete with a history- exam and MDM) be required.
I appreciate any help you can provide me
Our OBGYN dept has asked me to do an in-depth audit of their department... including more than what I typically audit; office visits, hospital services, OB triage, ultrasounds, Deliveries, surgeries, global OB care...
My question is what is required as far as documentation for the OB global package? Do we need a traditional office visit note for each time the patient is seen or is a prenatal flowsheet(ACOG) acceptable? I understand we do not bill each time the patient is seen but wouldn't a traditional note(complete with a history- exam and MDM) be required.
I appreciate any help you can provide me