Wiki What is needed from a provider's documentation for coding purposes?

[JAB86]

Hi,

Our business office does work for many family practices all over the state and I would like to come up with a questionaire for any new clients for the future. I was wondering what do you find helpful in a provider's/physician documentation from a medical record for coding purposes? Or What are IMPORTANT notes that the provider/physician should document for coding?

Example: Chief complaint, DX, ROS, Signature w/ credentials....


Thanks!

 

[snjberry]

A good rule for our practices is the basic who (patient and physician), when (symptoms or injury occurred), what (helps or doesn't), where (patient was in event it's an accident), how it happended, and why they are there. Not in this order.
so you do need chief complaint, ROS, PFSH, impression, plan...md signature or electronic signature
Sandi

 

[JAB86]

A good rule for our practices is the basic who (patient and physician), when (symptoms or injury occurred), what (helps or doesn't), where (patient was in event it's an accident), how it happended, and why they are there. Not in this order.
so you do need chief complaint, ROS, PFSH, impression, plan...md signature or electronic signature
Sandi

Thank you for your input!