lesterbelen
Contributor
Hello all! Didn't know which sub-forum to put this in so I am posting it here.
I work for a faculty practice group and my question is:
In the attending's progress notes, should the attending himself document/state the chief complaint or diagnosis that the patient has/is being treated for? Or is the attending's attestation that he/she "performed a history and physical exam of the patient and agrees with resident's findings and plan of care" enough for the coder to get the diagnosis from the resident's own progress note? Here is an example:
"Attending progress Note:
Progress Note: Pt is doing better. CXR showed no infiltrate. Will stop ABX
Supervision Review: I performed a history and physical examination of the patient and discussed his/her management with the resident/PA. I reviewed the resident's/PA's note and agree with the documented findings and plan of care."
I do not see a chief complaint/diagnosis but is the attestation enough for me to get the CC/dx from the resident's note? Or should the attending himself document it in his progress note?
Thanks for the help!
I work for a faculty practice group and my question is:
In the attending's progress notes, should the attending himself document/state the chief complaint or diagnosis that the patient has/is being treated for? Or is the attending's attestation that he/she "performed a history and physical exam of the patient and agrees with resident's findings and plan of care" enough for the coder to get the diagnosis from the resident's own progress note? Here is an example:
"Attending progress Note:
Progress Note: Pt is doing better. CXR showed no infiltrate. Will stop ABX
Supervision Review: I performed a history and physical examination of the patient and discussed his/her management with the resident/PA. I reviewed the resident's/PA's note and agree with the documented findings and plan of care."
I do not see a chief complaint/diagnosis but is the attestation enough for me to get the CC/dx from the resident's note? Or should the attending himself document it in his progress note?
Thanks for the help!
