Wiki Documentation requirements

[m.matos@chcfl.com]

Hi,
We are auditing our providers progress notes for documentation to support the diagnosis, medications given and labs ordered. I have learned that the current days progress note must be able to stand alone in supporting these components. Meaning I should be able to find all supporting documenation in that current days progress note. We are getting a lot of kick back from the providers because the documenation is supported out side of the progress note else where in the chart. Am I wrong in advising them it must be in that current days progress note or does documenatation from else where in the chart like a problem list, past progress notes and past labs count as supporting documentation. I feel like I have no hard core guidelines to back me up.

Thanks

 

[mitchellde]

What kind of information? The radiology results can be on the radiology report and does not need to be in the progress note. A path result can be on the path report only. So it depends on what you want. You cannot obtain current diagnosis from old progress notes, labs must interpreted by the physician in the current note. Each days results must stand alone for that day. Past results, past information, previous exam cannot be reviewed by the coder for current diagnosis.

 

[m.matos@chcfl.com]

As a coder i can not diagonsis from past documenation but can the provider? He is pulling diagnosis from past lab results and past progress notes but in the current days progress note there is no documenation to support. He feels that as long as the chart as a whole can support his diagnosis his current days progress note doesnt need to.

If were to get audited would they search throught the chart as a whole or reviewed only the current progress note for the supporting documentation.

Thanks