A patient came into the office for a nurse visit for spirometry (This was documented by the nurse). The visit turned into a level 4 by seeing our Physician. My question is: He starts out by stating Addendum: The documentation does not state Chief Complaint instead he documents as: Subject: Acute Dysuria If audited, would SUBJECT work as Chief Complaint? He goes on as: Additional Information: Total Time 15/25 minutes devoted face to face... Review of Systems - all documented. Testing: UA Reviewed/Discussed/Detained = all documented. Medication: ordered to start ..... Return to clinic .... PLEASE answer ASAP.
One other question: Sometimes pt comes for preventive visit which turns into regular office visit. Is there a certain amount of time needed for the preventive physical?
Thanks for your help. It is truly appreciated.
One other question: Sometimes pt comes for preventive visit which turns into regular office visit. Is there a certain amount of time needed for the preventive physical?
Thanks for your help. It is truly appreciated.