Wiki Documentation of Physical Examination

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kimberlydegrazia

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For proper documentation of a physical exam for a Level 5 established patient, is it acceptable for a physician to dictate vital signs only and then state "The rest of the examination is the same"?

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no... what does the provider mean by this statement? If he means same as a previous exam, no you cannot do that... the only part of a visit that may be brought forward is the ROS part of history and even then the physician must document the date and location of the ROS being referenced as well as that it has been reviewed with the patient.
The exam is the providers hands on of the patient's current state, it cannot be referenced to in this manner
 
Debra is correct - you can't do that. I've seen doctors bill a level 5 service and say things like "The exam is completely unremarkable" or "exam is unchanged from the visit on 11/5" .... these phrases are not acceptable. You are allowed to say things like "Lungs - Normal" or "Eyes - Negative" but that's about as easy as it gets, you can't just say the entire exam is normal and expect to get credit for a Comprehensive examination.

....I'm all for efficient documentation, so I can see where your provider is coming from, but they are going to have to document just a little more.
 
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