Wiki Emr coding

samyjm13

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I code for 7 providers in our clinic, but am new at coding EMR, does anyone have any tips, everything seems the same in the ROS. Any help would be appreciated.
Samy
 
Does the ROS appear the same from visit to visit (same patient)? This could be an issue of copying and pasting from visit to visit. Or...do the ROS's appear to be the same for every patient? One way to determine the authenticity of the data is to compare the chief complaint and the exam documentation to the ROS's. Example...if the patients CC is an asthmatic attack and the ROS indicate negatives and the exam indicates normal, you may have an issue.

Are your patient's given a ROS form to fill out at the time of service? If so, you could compare what the patient has indicated as negatives/positives against the information entered into the EMR.
 
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