Wiki Hospital Progress Note

[gniedermaier]

We are really having a difficult time trying to audit hospital progress notes (99231-99233) for our physician billing. They miss many of the key components because they are basically writing everything out on lined paper. These are not dictated and most often are very diffiuclt to read. Is everyone in the same boat and you basically have to pull out whatever you can? Do most hospitals have "blank" progess notes that the physicians and residents just hand write everything?

All feed back is appreciated

Gina Niedermaier, CMC

 

[Naveen Rachagolla]

EM Documentation

The best and Easiest way is to educate our physicians on how ot document the medical record and also we should teach them how its going to effect their reimbursement.