• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Ros

Create Wiki
A

amylynne69

Contributor
Messages
15
Best answers
0
If a provider has a list of systems and the patient or nurse circles the systems the patient has concerns with that day, but doesn't mark the other systems, and nobody says other systems are negative, can the other systems be counted if the office policy is that they discussed all of the systems and not marking them means they were negative? but in the chart there is not a statement about the other systems, it's just an office policy that if they aren't circled, they were negative.
 
No you cannot have an office policy substitute for documentation. It must be clear in the documentation that these were discussed with the patient and which were negative and which were positive. Anything not discussed cannot be counted.
 
You must log in or register to reply here.
Top