cjhalk@yahoo.com
Guru
Good Morning,
If a provider documents the HPI and the A&P word for word, is this considered cloning? Everything I find online specifically states cloning is defined as from one day to the next. However, is this considered cloning? If not cloning, is this ok or not ok? I cannot find anything online that says this is bad, so I am making an assumption this is ok.
HPI:
Narrative:
1 Proteinuria: The patient has proteinuria. He probably has some sort of nephritis. He had a biopsy today.
2. Hypertension: This is still somewhat elevated. I will address medications
3. Metabolic acidosis: He is on bicarbonate
4. Anemia: This is stable
5. History of juvenile rheumatoid arthritis: This is stable #6 gluteal abscess/pilonidal cyst: He is on empiric antibiotics.
A&P:
1 Proteinuria: The patient has proteinuria. He probably has some sort of nephritis. He had a biopsy today.
2. Hypertension: This is still somewhat elevated. I will address medications
3. Metabolic acidosis: He is on bicarbonate
4. Anemia: This is stable
5. History of juvenile rheumatoid arthritis: This is stable #6 gluteal abscess/pilonidal cyst: He is on empiric antibiotics.
hold Hep for bx, pt is ambulatory
Pt's spouse is surrogate in emergency
full code
If a provider documents the HPI and the A&P word for word, is this considered cloning? Everything I find online specifically states cloning is defined as from one day to the next. However, is this considered cloning? If not cloning, is this ok or not ok? I cannot find anything online that says this is bad, so I am making an assumption this is ok.
HPI:
Narrative:
1 Proteinuria: The patient has proteinuria. He probably has some sort of nephritis. He had a biopsy today.
2. Hypertension: This is still somewhat elevated. I will address medications
3. Metabolic acidosis: He is on bicarbonate
4. Anemia: This is stable
5. History of juvenile rheumatoid arthritis: This is stable #6 gluteal abscess/pilonidal cyst: He is on empiric antibiotics.
A&P:
1 Proteinuria: The patient has proteinuria. He probably has some sort of nephritis. He had a biopsy today.
2. Hypertension: This is still somewhat elevated. I will address medications
3. Metabolic acidosis: He is on bicarbonate
4. Anemia: This is stable
5. History of juvenile rheumatoid arthritis: This is stable #6 gluteal abscess/pilonidal cyst: He is on empiric antibiotics.
hold Hep for bx, pt is ambulatory
Pt's spouse is surrogate in emergency
full code