Wiki Documentation Requirements for Stating Dx, Medication, etc.

[KStaten]

For documentation purposes, is it required for the doctor to document each of the following:

A) Restate the diagnosis in the plan of care, if it is selected/ documented/listed in the diagnosis section.
B ) Restate the name of the drug / dosage in the plan of care or procedure dictation, if is selected/ documented elsewhere through orders, for example? (Can the doctor just document that an injection was given and then have the medication name / dosage listed elsewhere?)
C ) Restate the name/ number of views for an x-ray, if the number of views are selected/ documented elsewhere in the note through orders, for example?

Thank you.

 

[vinessachilders]

In my experience, it doesn't matter if the information is documented together or separate, just that it has to be documented somewhere. This would mean if it were documented in the assessment, it wouldn't have to be listed under plan as well. If the RX is documented under orders, it shouldn't have to be documented again on the plan, etc. There are 3 "sections" or "areas" of an encounter note: History, Physical Exams/Findings, and Assessment/Plan. If the information is documented in the "area", we were taught it could be "moved" within the area to wherever it needed to be.

For example, in the x-ray order, it states 2 views chest x-ray. As that is part of the Assessment/Plan area, the provider wouldn't have to retype or click the x-ray 2 views chest under a heading of Plan.

Does that help?