1. Common Documentation Guidelines/Issues
Todd M. Husty, D.O.
President/Owner, (M)edical (A)udit (R)esource (S)ervices, (I)nc.
10/16/18 Greater Orlando AAPC

2. OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES
CC-Chief Complaint History of CC
ROS – Review of Systems: Including Soc, Fam, Occ, Med/Surg
Physical Exam
Medical Decision Making
Limited Differential Diagnosis or Working Diagnoses or Potential Problem List
Diagnostic Impression

3. OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES
Pertinent Positives and Pertinent Negatives
Less severe problems
Problem focused exam and Hx
Minimal to moderate MDM
Shorter Diff Dx
Less testing
Fewer acute interventions

4. OUTPATIENT and INPATIENT DOCUMENTATION GUIDELINES
More severe problems
Expanded Hx and Physical
Complex MDM
Longer Diff Dx with more severe problems
More testing
More acute interventions

5. REASONS TO DOCUMENT Note to self - reminder, memory jog.
Note to others – physicians, nurses, respiratory, physical therapy.
Memorialize events – today’s visit becomes tomorrow’s past medical Hx.
Data gathering & reporting – non-clinical so Not important to us

6. OUTPATIENT DOCUMENTATION GUIDELINES
Interpreted Results of Tests/Procedures and/or therapeutic trials
Diagnostic Impression
Plan – Include medications, consults, procedures, follow up
Be “Necessarily Thorough”
SHOW WHAT WE DO
WE MAKE DECISIONS!

7. Common Mistakes in ED
Lots of tests and MDM…little HPI and other Hx like soc or family
RVUs and Docutemptation
Copy and paste
Size of lesions/lacerations…depth and structures involved…surgical debridement…layers of closure