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I am a CDI working at a hosptial with HCC Medicare Advantage patients. Physicians concern were:
What is the best way to document chronic conditions that the patient has during a sick visit. An example was someone being seen for a cold. Where in the medical record should the conditions be documented when the patient is being seen for something else?
How does the PCP document a condition that is being treated by a specialist, example CHF. They wanted to know if it needed to be in the assessment and plan or if they could just put it in the HPI.
I believe I have the answers but wanted to double check. Thank you for your help!
Diane
What is the best way to document chronic conditions that the patient has during a sick visit. An example was someone being seen for a cold. Where in the medical record should the conditions be documented when the patient is being seen for something else?
How does the PCP document a condition that is being treated by a specialist, example CHF. They wanted to know if it needed to be in the assessment and plan or if they could just put it in the HPI.
I believe I have the answers but wanted to double check. Thank you for your help!
Diane