Writing or Erasing the EHR Documentation Dilemma
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Is your provider documenting the elements of the physical exam performed or are they deleting items from a “normal” template to represent the work? Many providers document a detailed or comprehensive level Review of Systems (ROS) and Exam on all patients – because the template is there. The template has 9 or more elements which may be more than the selected E&M level requires. They then spend significant time reviewing complete ROS or comprehensive Exam to erase any items that are listed as normal. They then spend additional time re-documenting what the patient actually has. If they miss “erasing” an item, the chart will be in conflict and most likely fail on audit.
This lecture will show a methodology for documenting what the E&M code requires in a forward thinking environment. The provider can always document more. This approach is a time saver, is compliant and results in relevant documentation of the patients. 2-5-8 represents the exam elements of office E&M services level 3,4 and 5 and helps define the methodology.
Documentation of E&M
- What is needed for level of service?
- Carriers have indicated the will dis-regard information charted that is not relevant to the chief complaint of the patient
- Over documentation may be suspicious
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