Common Documentation Guidelines/Issues Todd M. Husty, D.O. President/Owner, (M)edical (A)udit (R)esource (S)ervices, (I)nc. 10/16/18 Greater Orlando AAPC

OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES CC-Chief Complaint History of CC ROS – Review of Systems: Including Soc, Fam, Occ, Med/Surg Physical Exam Medical Decision Making Limited Differential Diagnosis or Working Diagnoses or Potential Problem List Diagnostic Impression

OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES Pertinent Positives and Pertinent Negatives Less severe problems Problem focused exam and Hx Minimal to moderate MDM Shorter Diff Dx Less testing Fewer acute interventions

OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES More severe problems Expanded Hx and Physical Complex MDM Longer Diff Dx with more severe problems More testing More acute interventions

REASONS TO DOCUMENT Note to self - reminder, memory jog. Note to others – physicians, nurses, respiratory, physical therapy. Memorialize events – today’s visit becomes tomorrow’s past medical Hx. Data gathering & reporting – non-clinical so Not important to us

OUTPATIENT DOCUMENTATION GUIDELINES Interpreted Results of Tests/Procedures and/or therapeutic trials Diagnostic Impression Plan – Include medications, consults, procedures, follow up Be “Necessarily Thorough” SHOW WHAT WE DO WE MAKE DECISIONS!

Common Mistakes in ED Lots of tests and MDM…little HPI and other Hx like soc or family RVUs and Docutemptation Copy and paste Size of lesions/lacerations…depth and structures involved…surgical debridement…layers of closure