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Documentation (GEN)
Posted August 3, 2007
Record reviews by Medicare personnel reveal the necessity to discuss improved documentation. The evaluation and management visit should start with a chief complaint or complaints. Sometimes, the provider states the reason for a visit. It is also important to record what the patient states. If it is a "follow-up" visit, what is being followed up, what is the concern, or concerns? What questions does the provider intend to answer with the content of the visit? Lack of development of symptoms is one of the main problems noted in reviewing records. Chest pain might be considered a black box of potential disaster. Too often, it is recorded as "chest pain" without answers to probing questions which describe the character of the chest pain, where it occurs, where it radiates, what causes it to come on, what gives release, etc. Enhanced information helps to guide a provider and the reviewer to what measures are appropriate and most likely to be beneficial to the patient.
Often, multiple diseases, medications, etc., are briefly listed without development. The question for the reviewer is, what is being evaluated and what is being managed? The examination is based on the guidance of the information in the history. The history and examination should lead to stated management concerns, decisions, and plans. Please include comments which will establish what is currently being evaluated, what current problems are being managed and how. The focus on the task at hand, with succinct phrases can be used to avoid an excessively wordy product which provides significant deficits of information. An improved product starts with attention to, and intent to, improve. |
