Wiki Complete exam with "see previous"

[lillianivy]

Help! I have a physician who constantly uses this for his exam:

APPEARANCE:
well developed, well nourished,
Vital signs:
Laboratory, Pathology, and Vital Sign data were reviewed and noted
ECOG 0, patient in no acute distress.
See previous, no changes

What is this considered? I don't feel like this counts for a complete exam. I need clarification and also some sort of documentation to back this up, besides what is in the CPT guidelines, to be able to explain it to my physician. He has been informed that this is legit and I disagree. I have tried to supply resources to support my opinion but unsuccessful. Please help!!!!!!

Thank you,

Lydia

 

[hstrasko_rn@atlanticlegalnurseconsultants.com]

An ounce of provention is worth a pound of....

If your Dr were to take the time an attend a legal documentation seminar, he would definately come out of there writing a different note for his patients. This entry is a lot of "fluff" to me and I've been working in Nursing and the legal field for quite a while. (40 yrs) Now a days, many Drs and Nurses SOAP their notes. S=subjective "What the patient states" O=Objective "What do you see or observe? A= Assessment, putting it all together, the diagnostics done, what is your assessment of the situation. P=Plan of action. What measures are you going to take for this patient? When this form of charting is done, especially for patients returning for an O.V., new patients, etc. the Dr does NOT leave himself/herself open for possible legal recourse. There are many seminars geared towards the medical community given by Attorneys to assist them in protecting themselves. Contacting your local or county legal bar & looking up via the Internet what seminars are being offerred can be fruitful. Also, when in doubt, you can always check it out with a local attorney in your area who practices in the area of Health Law. Or, to contact the local bar association for a recommendation of attorneys who practice in the area of health laws.
I just attended our NJ State Bar's Convention and there were numerous seminars in this area and other fields of law. Best of luck!