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Wiki Physical Exam Documentation help

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hollee.hamilton

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I'm an internal auditor and I have run into some exam documentation that I have not encountered before. The physician is using "denies" within the exam section which to me is more like ROS documentation, not physical exam.
Musculoskeletal:
Wrists Denies swelling, denies tenderness
Ankles Denies swelling, denies tenderness
Feet Denies swelling, denies tenderness

I feel like this could be a potential issue with an outside auditor. Am I completely off base?:confused:
If not, would anyone be able to point me to information I could use to educate the physician?
Thanks!
Hollee Hamilton, CPC, CEMA
 
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I can see your concern with the documentation as a possible reference to ROS instead of exam. This would be a great talking point with your physicians to explain how the documentation could be perceived by an outside auditor. Possibly a suggestion could be made for the provider to document the examination as "no appearance of swelling; no tenderness to the touch or based on movement."

This is a good catch and it is always a good idea to suggest changes to eliminate any grey areas in documentation for audits and clarity.
 
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