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[amylynne69]

If a provider has a list of systems and the patient or nurse circles the systems the patient has concerns with that day, but doesn't mark the other systems, and nobody says other systems are negative, can the other systems be counted if the office policy is that they discussed all of the systems and not marking them means they were negative? but in the chart there is not a statement about the other systems, it's just an office policy that if they aren't circled, they were negative.

 

[mitchellde]

No you cannot have an office policy substitute for documentation. It must be clear in the documentation that these were discussed with the patient and which were negative and which were positive. Anything not discussed cannot be counted.

 

[amylynne69]

Thank you

Thanks. That's what I was thinking.