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Provider Not Documenting

DeniMCharlotte

Contributor
Messages
13
Location
Quincy
Best answers
0
I have a provider who is generally recording their HPI in the ROS. Is this acceptable and if not how do I approach this situation so that the provider understands that this is not acceptable?

Thank you.
 

Pam Brooks

True Blue
Local Chapter Officer
Messages
2,061
Location
Dover Seacoast New Hampshire
Best answers
0
Of course it's OK. Although as coders and auditors we'd love to see all of the key components of E&M neatly documented in the SOAP note format, that just doesn't happen in real life, even with an electronic health record.

It's the auditor's job to tease out that which is history, ROS and exam information and apply it to an audit tool from a medical necessity standpoint. I've seen HPI information in the assessment/plan, and I've seen exam components in the history portion. As long as it's documented, and you have the auditing skills to interpret the difference between the elements, I wouldn't chastise any provider unless your organization has a strict rule about how the EHR templates are to be used (which I've yet to see). You don't want to make this any harder than it has to be.
 
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