Medical Documentation Rules
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Medical Medical Documentation Documentation Rules Rules
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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 - PowerPoint PPT Presentation
Transcript of Medical Documentation Rules
Medical Documentation Medical Documentation RulesRules
Medical Documentation Medical Documentation RulesRules
Medical Documentation RulesMedical Documentation RulesGeneral principlesGeneral principles
The documentation of each patient encounter The documentation of each patient encounter should include:should include:
Chief complaintChief complaint Relevant history of present illness(HPI)Relevant history of present illness(HPI) Physical examinationPhysical examination FindingsFindings Prior diagnostic test resultsPrior diagnostic test results Assessment, clinical impression orAssessment, clinical impression or diagnosis.diagnosis. Plan for carePlan for care Date and legible identity of the observer.Date and legible identity of the observer.
Medical Documentation RulesMedical Documentation RulesGeneral principles…General principles…
The rationale for ordering diagnostic andThe rationale for ordering diagnostic and otherother ancillary services should be easily inferredancillary services should be easily inferred
Past and present diagnoses should be Past and present diagnoses should be accessible to the treating and/or consulting accessible to the treating and/or consulting physicianphysician
Appropriate health risk factors should be Appropriate health risk factors should be identifiedidentified
The patient’s progress,response to and changesThe patient’s progress,response to and changes in in treatment, and revision of diagnosis should betreatment, and revision of diagnosis should be documented.documented.
Medical Documentation RulesMedical Documentation Rulesgeneral principles…general principles…
Codes reported on the health Codes reported on the health insurance claim form or billing insurance claim form or billing statement should be documented in statement should be documented in the medical record.the medical record.
Patient’s confidentionalityPatient’s confidentionality Plan for care should be recorded and Plan for care should be recorded and
include patient teaching and include patient teaching and monitoring.monitoring.
Dosage and treatment scheduleDosage and treatment schedule
Medical Documentation RulesMedical Documentation Rulesgeneral principles…general principles…
Draw a line on mistakes, never erase Draw a line on mistakes, never erase the datathe data
Record Record counsulting:request,render,report.counsulting:request,render,report.
Medical Documentation RulesMedical Documentation Rulesdocumentation of historydocumentation of history
The levels of E/M services are based The levels of E/M services are based on four types of history:on four types of history:
Problem FocusedProblem Focused Expanded problem focusedExpanded problem focused DetailedDetailed comprehensivecomprehensive
Medical Documentation RulesMedical Documentation Rulesdocumentation of history…documentation of history…
Each types of history includes the Each types of history includes the following elements:following elements:
Chief complaint(CC)Chief complaint(CC) History of present illness(HPI):History of present illness(HPI): Past, family and/or social Past, family and/or social
history(PFSH)history(PFSH) Review of systems(ROS)Review of systems(ROS)
Medical Documentation RulesMedical Documentation Rules
Chief complaintChief complaint
Medical Documentation Rules Medical Documentation Rules chief complaintchief complaint
The CC is a concise statement The CC is a concise statement describing the describing the symptom,problem,condition,diagnosisymptom,problem,condition,diagnosis,physician recommended return,or s,physician recommended return,or other factor that is the reason for the other factor that is the reason for the encounter.encounter.
Medical Documentation RulesMedical Documentation RulesHistory of present illness(HPI)History of present illness(HPI)
HPI is a chronological description of HPI is a chronological description of the development of the patient’s the development of the patient’s present illness from the first and/or present illness from the first and/or symptom or from the previous symptom or from the previous encounter to the present. It includes encounter to the present. It includes the following elements:the following elements:
Medical Documentation RulesMedical Documentation RulesHPIHPI
Location Location QualityQuality SeveritySeverity DurationDuration TimingTiming context context
Modifying factorsModifying factors
Associated signs Associated signs and symptoms.and symptoms.
Medical Documentation RulesMedical Documentation Rulesdocumentation of historydocumentation of history
The levels of E/M services are based The levels of E/M services are based on four types of history:on four types of history:
Problem FocusedProblem Focused Expanded problem focusedExpanded problem focused DetailedDetailed comprehensivecomprehensive
Medical Documentation RulesMedical Documentation RulesPast, Family and/or SocialPast, Family and/or Social History(PFSH)History(PFSH)
Past: the patients experiences with Past: the patients experiences with illnesses,operations,injuries and illnesses,operations,injuries and treatments.treatments.
Family: review of medical events in Family: review of medical events in the family ,(hereditary or place the the family ,(hereditary or place the patient at risk)patient at risk)
Social; an age appropriate review of Social; an age appropriate review of the past and current activitiesthe past and current activities
Documentation of ExaminationDocumentation of Examination
InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation
Documentation of ExaminationDocumentation of Examination
Documentation of ExaminationDocumentation of Examination
Documentation of ExaminationDocumentation of Examination
Documentation of examinationDocumentation of examination
The levels of E/M servicesThe levels of E/M services Problem FocusedProblem Focused Expanded Problem Focused Expanded Problem Focused DetailedDetailed ComprehensiveComprehensive
Documentation of examinationDocumentation of examination P F:A limited examination of the body areaP F:A limited examination of the body area oror
organ system.organ system. Exp PF:Exp PF:AA limited examination of the limited examination of the affectedaffected
body area or organ system and otherbody area or organ system and other symptomatic or related organ system(s).symptomatic or related organ system(s).
Detailed: anDetailed: an extended examination of the extended examination of the affected body area(s) and other affected body area(s) and other symptomatic or related organ system(s).symptomatic or related organ system(s).
Com:a general multi-system examination or Com:a general multi-system examination or complete examination of a single organ complete examination of a single organ system.system.
Documentation of disease coarseDocumentation of disease coarse
Two methods:Two methods:11-admit note/follow-up -admit note/follow-up
note/treatment note/daily notenote/treatment note/daily note Progress noteProgress note Final noteFinal note
Documentation of Disease coarseDocumentation of Disease coarse
2-SOAP2-SOAP SubjectiveSubjective ObjectiveObjective AssessmentAssessment Plan of treatmentPlan of treatment
Documentation of the complexity of Documentation of the complexity of medical decision makingmedical decision making
The levels of E/M services recognize The levels of E/M services recognize four types of medical decision four types of medical decision making:making:
Straight-forwardStraight-forward Low complexityLow complexity Moderate complexityModerate complexity High complexityHigh complexity
Documentation of the complexity of Documentation of the complexity of medical decision makingmedical decision making
Documentation of Medical Documentation of Medical terminologyterminology
1-Diagnostic services1-Diagnostic services
2-Surgical services2-Surgical services
Documentation of Medical Documentation of Medical TerminologyTerminology
Do not use abbreviation in:Do not use abbreviation in: Final examinationFinal examination Management activitiesManagement activities External causes of emergenciesExternal causes of emergencies Death causesDeath causes
Documentation of Medical Documentation of Medical terminology…terminology…
It is recommended do not use It is recommended do not use abbreviations in:abbreviations in:
Discharge…(File summary sheet)Discharge…(File summary sheet) Surgical procedures…(Operation Surgical procedures…(Operation
report sheet)report sheet)
Documentation of Medical Documentation of Medical terminologyterminology
It is better to use the complete term It is better to use the complete term at first it appears then use the at first it appears then use the abbreviations for further refers.abbreviations for further refers.
Clarify precisely the anatomic site Clarify precisely the anatomic site and don’t use – or + for normal or and don’t use – or + for normal or abnormal findings.abnormal findings.
Documentation of Medical Documentation of Medical terminologyterminology
Surgical terms:Surgical terms: Simple lacerationSimple laceration Intermediate lacerationIntermediate laceration Complex lacerationsComplex lacerations
Documentation of MedicalDocumentation of Medical
Mention also:Mention also: Tools,facilities,and duration of their Tools,facilities,and duration of their
usageusage Kind of incisions; undermining, take Kind of incisions; undermining, take
down,lysis of adhesions( different down,lysis of adhesions( different tariff and codes).tariff and codes).
Patient Patient position;lithotomy,dorsal,vaginal…position;lithotomy,dorsal,vaginal…
Documentation of Medical Documentation of Medical terminology…terminology…
RUQ,LUQ,RLQ,LLQRUQ,LUQ,RLQ,LLQ Right hypochondriacRight hypochondriac Left hypochondriac, epigastric,right Left hypochondriac, epigastric,right
lumbar, left lumbar,umblical,right lumbar, left lumbar,umblical,right iliac,left iliac,hypogastriciliac,left iliac,hypogastric
Documentation RulesDocumentation Rules
Document while or just after Document while or just after performance.performance.
Do not ask the others to complete Do not ask the others to complete your document.your document.
