klrino
New
Hi all. I am stuck on something. I help out my former job with auditing once a month. I was auditing a Family Practice provider. He doesn't use the EMR. He has everything pre-printed and checks off and fills in additional information. For the personal interpretation of ekg's, x-rays and hearing tests he checks off the statement "Dr. A...has personally reviewed and interpreted..." On a particular ekg he just added "sinus rhythm normal." I code for a hospital and am used to more specific documentation. Would this be considered compliant? The checking off that personal review and interpretation was done and just adding a few words? I was thinking he needed to add that he looked at a few things and then he can add that results are normal or unremarkable for each. Any input would be appreciated. Thank you.