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Documentation from a form

  1. #1
    Lansing, Michigan
    Question Documentation from a form
    Exam Training Packages
    I was reviewing one of my doctor's charts and he noted "form completed" in his progress notes. When I reviewed the form I found information on the form that was not in the progress notes. Basically history information. I think my question is simply - can the information on the form be part of the documetation for the E/M code? when it is not in the actual progress notes? Thanks.

  2. #2
    Milwaukee WI
    Default NOT ideal reference
    "Form completed" isn't an ideal reference, but if it's all done on the same date of service and the form is clearly signed/dated by the physician, then, yes, I'd count it.

    A better documentation on the progress note would be: "Patient history form completed and reviewed by myself today. Please see form in chart for additional details."

    It only takes a few seconds for this "better" documentation, and it helps to make the progress note "audit proof."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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