Medical Documentation Rules
advertisement
Medical Documentation Rules Medical Documentation Rules General principles The documentation of each patient encounter should include: Chief complaint Relevant history of present illness(HPI) Physical examination Findings Prior diagnostic test results Assessment, clinical impression or diagnosis. Plan for care Date and legible identity of the observer. Medical Documentation Rules General principles… The rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified The patient’s progress,response to and changes in treatment, and revision of diagnosis should be documented. Medical Documentation Rules general principles… Codes reported on the health insurance claim form or billing statement should be documented in the medical record. Patient’s confidentionality Plan for care should be recorded and include patient teaching and monitoring. Dosage and treatment schedule Medical Documentation Rules general principles… Draw a line on mistakes, never erase the data Record counsulting:request,render,report. Medical Documentation Rules documentation of history The levels of E/M services are based on four types of history: Problem Focused Expanded problem focused Detailed comprehensive Medical Documentation Rules documentation of history… Each types of history includes the following elements: Chief complaint(CC) History of present illness(HPI): Past, family and/or social history(PFSH) Review of systems(ROS) Medical Documentation Rules Chief complaint Medical Documentation Rules chief complaint The CC is a concise statement describing the symptom,problem,condition,diagnosi s,physician recommended return,or other factor that is the reason for the encounter. Medical Documentation Rules History of present illness(HPI) HPI is a chronological description of the development of the patient’s present illness from the first and/or symptom or from the previous encounter to the present. It includes the following elements: Medical Documentation Rules HPI Location Quality Severity Duration Timing context Modifying factors Associated signs and symptoms. Medical Documentation Rules documentation of history The levels of E/M services are based on four types of history: Problem Focused Expanded problem focused Detailed comprehensive Medical Documentation Rules Past, Family and/or Social History(PFSH) Past: the patients experiences with illnesses,operations,injuries and treatments. Family: review of medical events in the family ,(hereditary or place the patient at risk) Social; an age appropriate review of the past and current activities Documentation of Examination Inspection Palpation Percussion Auscultation Documentation of Examination Documentation of Examination Documentation of Examination Documentation of examination The levels of E/M services Problem Focused Expanded Problem Focused Detailed Comprehensive Documentation of examination P F:A limited examination of the body area or organ system. Exp PF:A limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Com:a general multi-system examination or complete examination of a single organ system. Documentation of disease coarse Two methods: 1-admit note/follow-up note/treatment note/daily note Progress note Final note Documentation of Disease coarse 2-SOAP Subjective Objective Assessment Plan of treatment Documentation of the complexity of medical decision making The levels of E/M services recognize four types of medical decision making: Straight-forward Low complexity Moderate complexity High complexity Documentation of the complexity of medical decision making Documentation of Medical terminology 1-Diagnostic 2-Surgical services services Documentation of Medical Terminology Do not use abbreviation in: Final examination Management activities External causes of emergencies Death causes Documentation of Medical terminology… It is recommended do not use abbreviations in: Discharge…(File summary sheet) Surgical procedures…(Operation report sheet) Documentation of Medical terminology It is better to use the complete term at first it appears then use the abbreviations for further refers. Clarify precisely the anatomic site and don’t use – or + for normal or abnormal findings. Documentation of Medical terminology Surgical terms: Simple laceration Intermediate laceration Complex lacerations Documentation of Medical Mention also: Tools,facilities,and duration of their usage Kind of incisions; undermining, take down,lysis of adhesions( different tariff and codes). Patient position;lithotomy,dorsal,vaginal… Documentation of Medical terminology… RUQ,LUQ,RLQ,LLQ Right hypochondriac Left hypochondriac, epigastric,right lumbar, left lumbar,umblical,right iliac,left iliac,hypogastric Documentation Rules Document while or just after performance. Do not ask the others to complete your document.
