I was wondering if anyone have some resource to know what the documentation requirements during a routine prenatal visit are. There is provider who I feel is not documenting correctly. I dont see asessment/plan, i don't see weeks of gestation. Can someone give me more direction. Thank you
Example below: provider chart note
HISTORY AND PHYSICAL REVIEWED TODAY AND OTHERWISE AS NOTED, WAS FOUND TO BE UNCHANGED
The patient is here - accompanied by her husband
No significant complaints, no bleeding, discharge, headaches, or cramps. She reports good fetal movement.
No depression / anxiety feelings expressed by the patient.
Rhogam today
Nurse is always in the exam room when any pelvic exam is performed.
Example below: provider chart note
HISTORY AND PHYSICAL REVIEWED TODAY AND OTHERWISE AS NOTED, WAS FOUND TO BE UNCHANGED
The patient is here - accompanied by her husband
No significant complaints, no bleeding, discharge, headaches, or cramps. She reports good fetal movement.
No depression / anxiety feelings expressed by the patient.
Rhogam today
Nurse is always in the exam room when any pelvic exam is performed.
