Differences in how time will be documented should be reflected in physician notes when new Medicare guidelines take effect Jan. 1.[1] This example was created by Ronda Ash, president of RKAsh Consulting Associates. Contact her at ronda@rkashconsulting.com.
Note Samples
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The current guideline states ~ document the total length of time of the encounter, and the record should describe the counseling and/or activities to coordinate care.
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Going forward, the note should look something like this:
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Mrs. Ispendalotoftime presents to the office today with shortness of breath and pain upon inhalation. She states that a recent airplane trip exposed her to “plane germs.”
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ROS – shortness of breath, pain on breathing; no other chest pain or abnormal pulse, remaining ROS is neg.; Other histories remain unchanged, although a new medication was added to her daily meds for rheumatoid arthritis, reviewed (DOS, location, initials);
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Exam shows that there are rales in the LLL, heart is RRR with no murmur or gallops;
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Chest X-ray ordered in-house, image reviewed personally, interpretation reveals slight shadow in LLL consistent with pneumonia;
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Plan – begin steroid and Zpak, patient had questions regarding the interactions of her medications and hygiene practices to follow when traveling.
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Total time today – 45 min.
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