AprilSueMadison
Expert
I'm trying to encourage our providers to document better. This is proving to be difficult, but I'm gaining some headway in the process.
One of our doctors uses "Pt is here for a general exam" only as the CC. Is there a better way we can expand that?
My thoughts are that the patient is here for something. Sun damaged skin, a suspicious spot, something of the sort that can be documented better. So far it's working well when the MAs fish for more information and ask better questions.
My question is what is the patient truly has no concerns except they are here for a yearly exam? How can I expand the CC in that case? I read somewhere that I should have how long it has been since the last exam, such as "Pt here for a general exam, it has been approx 2 years since the last one".
I'd truly appreciate any help on this, I feel like I'm in over my head for sure.
One of our doctors uses "Pt is here for a general exam" only as the CC. Is there a better way we can expand that?
My thoughts are that the patient is here for something. Sun damaged skin, a suspicious spot, something of the sort that can be documented better. So far it's working well when the MAs fish for more information and ask better questions.
My question is what is the patient truly has no concerns except they are here for a yearly exam? How can I expand the CC in that case? I read somewhere that I should have how long it has been since the last exam, such as "Pt here for a general exam, it has been approx 2 years since the last one".
I'd truly appreciate any help on this, I feel like I'm in over my head for sure.