LLRodgers
Guest
Hi,
I am a new coder and I have a question if anyone can help guide me.
If I have report that I am coding and the doctor indicates
"Past History,Social History, Family History reviewed with the patient and dated and initialed by me in the patient's chart"
I have been pulling the chart to check to make sure it is dated and initialed or signed by the doctor. Should I continue to do so or is what he dictates enough?
It does get a little tidious pulling the charts all the time and this happens quite frequently at our office.
Any advise is very much apprecited!
Thank you,
Linda
I am a new coder and I have a question if anyone can help guide me.
If I have report that I am coding and the doctor indicates
"Past History,Social History, Family History reviewed with the patient and dated and initialed by me in the patient's chart"
I have been pulling the chart to check to make sure it is dated and initialed or signed by the doctor. Should I continue to do so or is what he dictates enough?
It does get a little tidious pulling the charts all the time and this happens quite frequently at our office.
Any advise is very much apprecited!
Thank you,
Linda