I would like some advice on the following scenario:
Patient was scheduled for a follow-up visit with an NP which was to be billed as an 'incidnet to' visit. During the visit the patient voice a new problem, the MD came into the room, examined and began the treatment plan for the new problem but forgot to document it in the patients record. The physician is asking if it be acceptable to make a late entry and document the exam and treatment plan. The patient was seen several weeks ago. Thanks
Patient was scheduled for a follow-up visit with an NP which was to be billed as an 'incidnet to' visit. During the visit the patient voice a new problem, the MD came into the room, examined and began the treatment plan for the new problem but forgot to document it in the patients record. The physician is asking if it be acceptable to make a late entry and document the exam and treatment plan. The patient was seen several weeks ago. Thanks