# Documentation



## slindamood (Aug 12, 2010)

We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?


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## rthames052006 (Aug 12, 2010)

suzanna said:


> We have some physicians who think that it is appropriate & adequate to have a one page check list as their documentation for a patient visit. This check list provides the basic S.O.A.P format but there is very little to no elaboration from the physician on assessment or treatments involved with patient's diagnosis. I am afraid that this is not sufficient enough documentation. Can a physician completely replace a written/dictated note with a check sheet?



I too would be leary of a check list for the entire documentation of a visit.  Do they elaborate on the positive pertinent findings on exam?

can you give an example of what their a/p looks like.


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## sbicknell (Aug 13, 2010)

Not using an EMR???

Unless the check-list form allowed some written notes I don't see how he would document an HPI, any positive ROS and most important his MDM (here is what I think and how I plan to treat)

ERs used to use these kind of forms but they were multi-page. Is that what he is trying to copy?  I guess I would not want to go thru an audit trying to defend a 1-page check list


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## slindamood (Aug 13, 2010)

*documentation problem*

This is an example of the a/p.:

A: Acute Diagnosis                            P:
1.Alzheimers                                    1. Advanced
2. CHF                                             2. Controlled
3. HTN                                             3. Stable

The sheet does provide some places for notes, but not a lot & they docs never really utilize it much. I am looking for some kind of black & white proof that this is not enough  but I'm not having any luck.


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## rthames052006 (Aug 31, 2010)

suzanna said:


> This is an example of the a/p.:
> 
> A: Acute Diagnosis                            P:
> 1.Alzheimers                                    1. Advanced
> ...



I know my local carrier would accept #3.  I'm a bit leary on #1 & 2.  I can see where some education would be needed here.  They should elaborate more


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