Years ago, I worked with an Orthopedist who needed hours less sleep than I or the average person needed. While it would be incorrect to say he never slept, he woke up early, did his administrative tasks before his wife and kids were awake and arrived for work on time and ready to go. But, he’s not the subject of this article. No, my concern is the doctor whose claims look like she never sleeps, who reports such a high volume of services in a … [Read more...]
Written for coders and medical professionals, Nicoletti Notes is a coding blog designed to keep you up-to-date with coding news and refreshers. Nicoletti Notes is written by CodingIntel founder and coding expert Betsy Nicoletti.
The history of the present illness should be longer than a tweet and twice as informative. Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing. Why bring this up in the context of electronic health records? Because too often, the HPI in EMR notes is shorter than a tweet. And less informative. The history of the present illness describes the reason for the visit and … [Read more...]
“I have a normal exam template that I always use.” All right, I know baseball season is over, and it is hunting season in Vermont, so maybe I should title this, “Don’t shoot yourself in the foot.” The government and private payers have cloned notes in their line of vision. And, physicians and Non-Physician Practitioners (NPPs) can make it too easy for the payer to challenge an EMR note. How? The same history and exam for every … [Read more...]
“My medical assistant populates the past medical, family and social history in every note.” Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation. I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we implored physicians to add detail to their notes, describe their clinical thinking more fully and in … [Read more...]