tobieforte
Networker
Auditing is new to me and in my office we are trying to re-work our E/M documentation for our charts. If we have our ROS information on 1 page, our vitals on another page, and then the doctor's dictation on a 3rd typed page, if we would be audited, would the auditor put those 3 pages of information together? Would they give points for the ROS and vitals info if they are not in the dictation? Should our doctors take the time to dictate the ROS and vitals into the dictation? I'm afraid that they are not being allowed the correct level of E/M if they do not include this info. Thanks for your help.