Documentation Requirements: Normal Enough?

September 1, 2008

One of our doctors has a standard progress note form. The physical examination part of that form is titled simply by body system. The doctor commonly hand-writes “normal” next to each system without describing specifically what part is normal. For example, he doesn’t write “lungs are clear, heart rate is normal without murmur, abdomen is soft and nontender,” and the like. Is this adequate documentation to use when meeting criteria for a level three or level four visit?

Question: One of our doctors has a standard progress note form. The physical examination part of that form is titled simply by body system. The doctor commonly hand-writes “normal” next to each system without describing specifically what part is normal. For example, he doesn’t write “lungs are clear, heart rate is normal without murmur, abdomen is soft and nontender,” and the like. Is this adequate documentation to use when meeting criteria for a level three or level four visit?

Answer: Please see page 23 of the Medicare documentation guidelines. It states that “normal” is sufficient for reporting on unaffected systems, though it’s not OK just to say an entire system is normal. Certainly, if he is testing blood pressure, etc., he’ll also want to document concrete findings.