Wiki ROS from Chief Complaint

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AmyLitterell

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I'm new to auditing and one of the Physicians I'm working on typically dictates all of his HPI & ROS in 1-2 paragraphs under the the heading of Chief Complaint. My question is this: is it ok to take HPI & ROS info from these paragraphs? :confused:

Thank you!!
Amy
 
Yes. I have some providers that dictate one lump paragraph. Others use the SOAP format. I ususally use highlighters for lengthy dictations so that I can keep track of what areas I credit for each section.
 
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