Forum - Questions & Answers

Apr 2nd, 2009 - charrte

Documentation of H&P

I work in a teaching facility. I audit for about 20 physicians. 12 hospitalist and 8 MCCS. I can't put my finger on it, so I need help in determining if I have simply lost my mind or am I being the "anal" auditor.

The physician reports a 99223. I pull documentation to audit andthe entry is
"full note dictated." That is all the physician has written for the H&P. Yes, a H&P was dictated, but where did the info come from. Am I nuts, or is this sloppy documentation. Keep in mind, we are a teaching facility, so maybe the physician was trying to "link with the resident"

Does anyone have any opinions on this? Would you accept that as documentation?

Thanks in advance

Terie

Apr 2nd, 2009 -

Documentation of H&P

Who dictated the H&P--the resident or the attending? If it's the resident, then I agree with you. The attending note must be more than that. You can find examples in the Medicare Claims Processing Manual, http://www.cms.hhs.gov/Manuals/IOM/list.asp
Publication 100-04, Chapter 12, Section 100

Betsy

Apr 2nd, 2009 -

Documentation of H&P

If the attending dictated it, why do you think the work was done by the resident? Has that happened before?

If I saw a note dictated by the attending I would assume (always dangerous...) that the attending did the work.

Apr 2nd, 2009 - ERcoder   1 

Documentation of H&P

I think it is the opposite of sloppy. I would much perfer the MD dictate their notes instead of handwritting them. And them documenting "see dictation" in the progress note simply directs you where to find their documentation of the encounter. I would agree with Betsy in that if the attending did a dictation I would give them full credit for the content of the dictation.

Most dictations have a series of initials under the signature line that shows who dictated the note and who transcribed the note. So a dictation that looks like this:
____________________
Betsy Nicoletti
bn/tt

means that Betsy dictated the note and I typed it. What you have to watch our for is a signature line that looks like this:
____________________
Betsy Nicoletti
jd/tt

This means that Betsy had the resident do the dictation, I typed it and Betsy simply signed off on the resident note.

Hope this helps.
TT



Apr 2nd, 2009 -

Not good medicine

If the dictated document contains all the elements to be a 99223 then the coding is correct. There is no rule that the written note must contain all elements.

But this note is of no use to other providers who are looking at the chart. If your transcription turnover is under 30 minutes then it's ok. if no, the consultants called to see the patient will have no idea why they were called, what the primary doc is thinking, and the nurses will be clueless when the family or patient asks what the doctor said. At least "admitted for chest pain, rule out MI" or "acute renal failure, possibly NSAID, call nephrology, hydrate, check ultrasound."

All the emphasis on coding has led many to forget that the chart is foremost a method of communication between the members of the health care team.



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