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Documentation Requirements: Normal Enough?
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.
Asset Protection and Financial Planning
December 6th 2021Asset protection attorney and regular Physicians Practice contributor Ike Devji and Anthony Williams, an investment advisor representative and the founder and president of Mosaic Financial Associates, discuss the impact of COVID-19 on high-earner assets and financial planning, impending tax changes, common asset protection and wealth preservation mistakes high earners make, and more.
Reducing burnout with medical scribes
November 29th 2021Physicians Practice® spoke with Fernando Mendoza, MD, FAAP, FACEP, the founder and CEO of Scrivas, LLC, about the rising rates of reported burnout among physicians and how medical scribes might be able to alleviate some pressures from physicians.
