AprilSueMadison
Expert
I am doing a lot of reading of records today and finding little things I'm not for sure of or simply don't like.
One of my doctors puts reminders in the patient's medical record. For example, he might write "This patient is participating in the City Traditional Golf Game" so that the next time he sees the patient, he remembers to ask how they fared at the game!
It's in the patient's medical record, under a specific date of service...not just as a note. So these details may be listed under the HPI section. While I understand he wants to connect with his patients, isn't this considered overdocumentation? Sometimes I find PARAGRAPHS about the patients personal life, who they may be related to, what they did over the weekend, and the like.
I personally think this doesn't need to be in the medical record, but I've been informed I'm going to have a hard time getting him to stop. I'd like the opinion of other, more knowledgeable coders if possible! Thank you!
One of my doctors puts reminders in the patient's medical record. For example, he might write "This patient is participating in the City Traditional Golf Game" so that the next time he sees the patient, he remembers to ask how they fared at the game!
It's in the patient's medical record, under a specific date of service...not just as a note. So these details may be listed under the HPI section. While I understand he wants to connect with his patients, isn't this considered overdocumentation? Sometimes I find PARAGRAPHS about the patients personal life, who they may be related to, what they did over the weekend, and the like.
I personally think this doesn't need to be in the medical record, but I've been informed I'm going to have a hard time getting him to stop. I'd like the opinion of other, more knowledgeable coders if possible! Thank you!