Professional Documents
Culture Documents
July 7, 2009
If it is not documented,
it is not done and
therefore not billable!
Accuracy is of the Utmost
Importance
Legibly document what you
have done.
Something that may seem
trivial for you to document
could be the reason you could
bill a higher level of service.
Principles of Documentation
History
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)
Exam
Medical Decision Making (MDM)
Assignment of the E&M Code
Constitutional Musculoskeletal
Eyes Integumentary
ENT Neurological
Cardiovascular Psychiatric
Respiratory Allergic/Immunologic
Gastrointestinal Endocrine
Genitourinary Hematologic/Lymphatic
Past, Family & Social History
Can be obtained once in the medical
record and then referred to at
subsequent visits, with additions or
changes added, as encountered
Must be initialed and dated to
validate review by provider
Examination
Based on
Complexity of the diagnosis/management options
Amount of complexity of data reviewed
Risk to the patient
Documentation of the MDM is hardest to quantify
Putting providers thought process on paper
Medical Decision Making