AprilSueMadison
Expert
I'm just starting to audit documentation. We use our Nextgen EHR and the templates within it to document office visits, skin cancer screenings, surgeries and more.
The one thing I notice is that when we use our templates, we get the exact same wording for different visits over and over and over again. It's not an issue of copy and paste, but we may see the following: (note one is intermediate and one is complex) -
"All closure options were carefully considered. Due to the anatomic location of* the surgical wound, to minimize sacrifice of normal tissue while optimizing functional results, and disrupting the fewest cosmetic units, an intermediate repair was felt to be the best option to close this particular surgical wound."
"All closure options were carefully considered. Due to the anatomic location of* the surgical wound, to minimize sacrifice of normal tissue while optimizing functional results, and disrupting the fewest cosmetic units, a complex repair was felt to be the best option to close this particular surgical wound."
Obviously, with complex closures there is more information such as undermining and the like....but my question is...
is this an issue? They specify the surgery site, if anything changes, how the patient did.
I really need some guidance with this. Thank you. (expect many more posts as I continue to work my way through this lol)
The one thing I notice is that when we use our templates, we get the exact same wording for different visits over and over and over again. It's not an issue of copy and paste, but we may see the following: (note one is intermediate and one is complex) -
"All closure options were carefully considered. Due to the anatomic location of* the surgical wound, to minimize sacrifice of normal tissue while optimizing functional results, and disrupting the fewest cosmetic units, an intermediate repair was felt to be the best option to close this particular surgical wound."
"All closure options were carefully considered. Due to the anatomic location of* the surgical wound, to minimize sacrifice of normal tissue while optimizing functional results, and disrupting the fewest cosmetic units, a complex repair was felt to be the best option to close this particular surgical wound."
Obviously, with complex closures there is more information such as undermining and the like....but my question is...
is this an issue? They specify the surgery site, if anything changes, how the patient did.
I really need some guidance with this. Thank you. (expect many more posts as I continue to work my way through this lol)