amccracken1108
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Hello Everyone,
I have a provider who is adult medicine. So we all know the provider is seeing patients on follow up on labs and just follow ups on all their conditions. I have recently realized the provider is copying the hpi from the previous note into the current hpi and editing a few things here and there. They do update the conditions if they are stable or worsening based on the visit but they leave in all the previous information that is not in the assessment because they weren't assessed. Another problem is the provider writes the plan in the hpi with it....
Ex. HTN not at goal adding (med)
The problem I am trying to get across is that on this visit they didn't prescribe that med, it was prescribed 2-3 visits ago. I am trying to find some kind of document that I can show and get across the point that copying the hpi info should not be happening because its also leaving old information in there from previous visits that are not happening at this visit. I have audited a few charts and the old info doesn't change the outcome of the code because of all the other information that was current. The medical director is asking if it isn't having an effect on the billing why do we need to change it.
I know we need to change it because its not right to copy and paste the old stuff but I need something to show them and not just my word. Can anyone help?
I have a provider who is adult medicine. So we all know the provider is seeing patients on follow up on labs and just follow ups on all their conditions. I have recently realized the provider is copying the hpi from the previous note into the current hpi and editing a few things here and there. They do update the conditions if they are stable or worsening based on the visit but they leave in all the previous information that is not in the assessment because they weren't assessed. Another problem is the provider writes the plan in the hpi with it....
Ex. HTN not at goal adding (med)
The problem I am trying to get across is that on this visit they didn't prescribe that med, it was prescribed 2-3 visits ago. I am trying to find some kind of document that I can show and get across the point that copying the hpi info should not be happening because its also leaving old information in there from previous visits that are not happening at this visit. I have audited a few charts and the old info doesn't change the outcome of the code because of all the other information that was current. The medical director is asking if it isn't having an effect on the billing why do we need to change it.
I know we need to change it because its not right to copy and paste the old stuff but I need something to show them and not just my word. Can anyone help?