Physician needs proof

Tazlar

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One of the physicains I code for does not think she needs to add the diagnosis to the assessment portion of the EMR. She likes to use the special history and put everything in there. She feels that to put the diagnosis in the assessment is doing double documentation and she does not like to do things more than once. Can I pull the diagnosis from the special history? Is there someplace to find documentation to prove this needs to be completed a certain way? This continual conversation we have is becoming tiresome at best. thank you to anyone who may have more information or words of wisdom for me...
 

PediatricPenguin

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Depending on the EMR this physician is likely to have incomplete charts.

While proper coding/billing might be your purview, correctly using the EMR is a duty of a manager.

As for you pulling the diagnosis, as long as it is correctly documented somewhere for the correct date of service and then the chart has documentation to back that up, then you ought to be in the clear. This still doesn't excuse poor charting and a manager should address this.
 
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