TThivierge
True Blue
Hello,
I have some questions related to documentation by provider when abstracting or auditing the current medical documentation.
1. If the patient is dealing with a ongoing illness(chronic condition) but treated by another medical specialist doctor should the current physician list it under the dx assessment? Do you add the dx code if current or code it?
2.If a patient has Cancer, older than 5 years and it is gone, you would add to patient history using dx blocks of Z85 especially if pertaining to current illness. I know providers are to list years or when cured for past illnesses. But if pt is getting chemotherapy or cancer meds do you count the cancer on the list of current dx if physician forgets ? Or query him or her ?
3.If a provider adds an addendum after 3 days from original date treated: can you add it onto the dx assessment of a current illness?
4. The patient gives the NOC or Chief complaint plus it is listed in the Review of System section and the symptom or abnormality is noticed by the provider. However he or she FORGETs to put it in the current list of dx and assessments? Would you add the dx or symptoms from the provider s note under ROS plus addressed in his HPI section or query the doc for more data?
Thanking you in advance
Lady T
I have some questions related to documentation by provider when abstracting or auditing the current medical documentation.
1. If the patient is dealing with a ongoing illness(chronic condition) but treated by another medical specialist doctor should the current physician list it under the dx assessment? Do you add the dx code if current or code it?
2.If a patient has Cancer, older than 5 years and it is gone, you would add to patient history using dx blocks of Z85 especially if pertaining to current illness. I know providers are to list years or when cured for past illnesses. But if pt is getting chemotherapy or cancer meds do you count the cancer on the list of current dx if physician forgets ? Or query him or her ?
3.If a provider adds an addendum after 3 days from original date treated: can you add it onto the dx assessment of a current illness?
4. The patient gives the NOC or Chief complaint plus it is listed in the Review of System section and the symptom or abnormality is noticed by the provider. However he or she FORGETs to put it in the current list of dx and assessments? Would you add the dx or symptoms from the provider s note under ROS plus addressed in his HPI section or query the doc for more data?
Thanking you in advance
Lady T
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