Wiki Assessments

[parker777]

Our physicians like to list multiple problems under assessments, regardless of what the chief complaint is. Example: patient comes in with a sore throat, cough, etc. Physician lists sinusitis in the assessment, and then lists diabetes mellitus, hypertension, hyperlipidemia, asthma, etc. My question is: under the Plan: should all of the assessments be addressed independently or can they just address the sinusitis and list everything else as Others and list medication patient is taking for each, or should they only list the sinusitis since this is why the patient presented (CC). My understanding is that nothing should be listed under the assessment unless it has been addressed in the chief complaint, HPI and progress note. Thanks for any advice you can give!

 

[btadlock1]

Our physicians like to list multiple problems under assessments, regardless of what the chief complaint is. Example: patient comes in with a sore throat, cough, etc. Physician lists sinusitis in the assessment, and then lists diabetes mellitus, hypertension, hyperlipidemia, asthma, etc. My question is: under the Plan: should all of the assessments be addressed independently or can they just address the sinusitis and list everything else as Others and list medication patient is taking for each, or should they only list the sinusitis since this is why the patient presented (CC). My understanding is that nothing should be listed under the assessment unless it has been addressed in the chief complaint, HPI and progress note. Thanks for any advice you can give!

I agree with you. I've seen physicians do this too, and I don't give credit for them, unless they've documented enough information to qualify for credit under HPI for chronic conditions (eg, detailing the treatment plan, current status of the illness, any episodes pertaining to the illness, and/or any changes to the medication/treatment regimen). If they don't have enough documented on the problem to support a separate E/M from the info pertaining to the Chief Complaint, then they don't get extra credit, just because the patient happens to have the other illness. Just my opinion, though. Hope that helps!