Wiki Medical Documentation

[dklepper]

Hi, I was wondering who would be approved to fill out provider "annual comprehensive forms"? Our providers are paid incentives for completing their annual wellness exams. The wellness forms are in lieu of the progress notes or could be use in addition to the progress notes. The issue I have is that the providers do not fill out the forms, the office staff does. They transfer the diagnosis info, status and plan of care to the form and then I review the forms for missing HCC's. I am questioning the plan of cares and I an unsure if office staff should be filling these forms out? Any thoughts?
Thank You

 

[Chelle-Lynn]

A couple of questions...

1. On the annual comp forms, what information is being documented....exam? MDM?
2. Does the physician sign off on the form once completed?

 

[dklepper]

The exam assessment, diagnosis and plan of care are documented. Also the HEDIS measures are being marked on the form. The provider does sign off of the forms.