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Documentation

  1. Question Documentation
    Exam Training Packages
    We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?

  2. #2
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    Quote Originally Posted by suzanna View Post
    We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?
    I too would be leary of a check list for the entire documentation of a visit. Do they elaborate on the positive pertinent findings on exam?

    can you give an example of what their a/p looks like.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. Default
    Not using an EMR???

    Unless the check-list form allowed some written notes I don't see how he would document an HPI, any positive ROS and most important his MDM (here is what I think and how I plan to treat)

    ERs used to use these kind of forms but they were multi-page. Is that what he is trying to copy? I guess I would not want to go thru an audit trying to defend a 1-page check list

  4. Default documentation problem
    This is an example of the a/p.:

    A: Acute Diagnosis P:
    1.Alzheimers 1. Advanced
    2. CHF 2. Controlled
    3. HTN 3. Stable

    The sheet does provide some places for notes, but not a lot & they docs never really utilize it much. I am looking for some kind of black & white proof that this is not enough but I'm not having any luck.

  5. #5
    Default
    Quote Originally Posted by suzanna View Post
    This is an example of the a/p.:

    A: Acute Diagnosis P:
    1.Alzheimers 1. Advanced
    2. CHF 2. Controlled
    3. HTN 3. Stable

    The sheet does provide some places for notes, but not a lot & they docs never really utilize it much. I am looking for some kind of black & white proof that this is not enough but I'm not having any luck.
    I know my local carrier would accept #3. I'm a bit leary on #1 & 2. I can see where some education would be needed here. They should elaborate more
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

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