Wiki Question on documentation in chart


Local Chapter Officer
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I have just been assigned to code a new department within my organization. I've looked at some of the charts and I have some questions on how to proceed. This is a clinic that deals with long term chronic conditions and some patients have been coming for years. The doctors will put almost all HPI's in every subsequent chart, so I am seeing HPI's from 2014 until most recent appointment. The doctors will state some of the patients history like hypertension, paraplegia, or smoking status here and will assign the codes, even if this was mentioned months to years before and not mentioned again. they just carry the codes forward.

Question one: I should only be looking at the most recent encounter HPI. If I don't see a reference to hypertension, paraplegia, or smoking status within this most current HPI, ROS, or Exam it should not be coded.

Where in the chart should these be stated since they are chronic conditions?

Should I go ahead and code issues such as infections that the doctors don't list as a diagnosis?

Also, these patient come and have nursing visits. For these encounters diagnosis are put in and they don't reflect what they are coming in for.

I guess my overall question is: Since the doctors put so much other information into different parts of the chart, what can I use and not use. Plus, would I have to Query the doctors every time I see something that should be coded, or Query them to delete codes that I don't see documented in the chart.
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Chart Documentation


Looks like you need to schedule a meeting with your providers. The Providers job is to document correctly. If the follow-up team ends up having to appeal claims, they would not support the claim and be denied. In this case you'd need to query the provider; not sure that they would like this as it interupts their schedules. Many providers don't know they are not charting correctly until it is brought to their attention.