Remind them that all they have to document is 4 little tiny HPI elements, and give them examples of questions to ask that lead the patient to use describe why they're there. (What hurts?-location When did it start hurting?-duration Describe the pain.-quality How often does it bother you?-timing - Have you taken anything for it?-modifying factor, etc.) It's really not that hard, and if they don't do it, then they don't get credit for it in the audit. The best that documentation can be used for is ROS, and without any HPI more ROS isn't going to help the overall code selection. Hope that helps...
Brandi Tadlock, CPC, CPMA
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