I am not a skilled auditor, so I was wondering if someone with more experience could chime in on how to relay something to a provider. When they see a patient of course they document the areas checked, but then under their impression/plan they'll list something like this:
1. Acral Nevus - 3 mm even dark brown macule located on the body throughout
2. Benign Nevi - Regular, symmetrical, evenly-colored macules and papules distributed on the body throughout.
The words "body throughout" are what I'm needing to address. Most of the time, when this provider documents a patient as having a benign condition (benign nevi, cherry angiomas, Lentigines, etc.), it is documented as "located on the body throughout" - lots and lots of the chart notes are documented this way.
All of the other providers in the practice document the specific location for each specific patient; they never use the words "body throughout" and the others want all providers to document the same way and be specific across the board.
Wouldn't we want to list specific locations for each specific patient? I mean, every patient that has cherry angiomas can't possibly have them all over. In addition, you wouldn't want to say a patient has it all over if they really only have it on their arms and legs....
The note needs to be specific to each patient and this general term "body throughout" could cause red flags if all patients are documented the same way. What else do/should I explain to the provider?
1. Acral Nevus - 3 mm even dark brown macule located on the body throughout
2. Benign Nevi - Regular, symmetrical, evenly-colored macules and papules distributed on the body throughout.
The words "body throughout" are what I'm needing to address. Most of the time, when this provider documents a patient as having a benign condition (benign nevi, cherry angiomas, Lentigines, etc.), it is documented as "located on the body throughout" - lots and lots of the chart notes are documented this way.
All of the other providers in the practice document the specific location for each specific patient; they never use the words "body throughout" and the others want all providers to document the same way and be specific across the board.
Wouldn't we want to list specific locations for each specific patient? I mean, every patient that has cherry angiomas can't possibly have them all over. In addition, you wouldn't want to say a patient has it all over if they really only have it on their arms and legs....
The note needs to be specific to each patient and this general term "body throughout" could cause red flags if all patients are documented the same way. What else do/should I explain to the provider?