Wiki Subjective vs Objective

[michelef65]

I have a physician that tends to lump his objective/physical exam with his subjective portion of his dictation. Can I use the objective portion from the subjective portion of his dictation for documentation of the physical exam?

Any thoughts would be greatly appriciated.

Thanks,
Michele

 

[LLovett]

There is no rule on how a note has to be laid out. As long as the elements are there you can count them regardless of where they are physically located in the note.

It is much easier for the person reading the note after the fact, from both auditing and clinical points of view, if there is structure to the note so you might try and talk to the provider about that. Maybe get them a template to help organize their dictation or hand written note, whatever the case may be.

On days like today, I would be happy for any elements of exam anywhere, lol.

Good luck,

Laura, CPC

 

[FTessaBartels]

One long paragraph

Yes, I know physicians who dictate one long paragraph ... everything is lumped together and I'm left to sort it out.

Yes, as long as you can clearly sort out what is objective, you may use it for exam.

But it never hurts to try to educate the physician to make things easier on him/herself AND the auditor by organizing their notes (or at least breaking it up into separate paragraphs).

F Tessa Bartels, CPC, CEMC

 

[ARCPC9491]

I agree with the above posts... while we wish, pray, and hope they would "clearly dictate" every little component (that we look for) seperately... we just couldn't get that lucky.