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requirements of documentation for Estabished Follow-up

Sophie Posted Tue 18th of September, 2012 13:10:56 PM

Do you have to document assessment if you document a plan of care in visit note for estab f/u pt?

We just updated our EMR system and for our remicade infusion patients the template that was formatted allows for the physicians to document the following information:
-indication
-HPI
(NO ROS or PFSH)
(NO PE)
(NO assessment)
-plan of care

I thought that ALL office visit notes required assessment and plan of care. OR ARE THESE TWO 'ASSESSMENT/PLAN' ONE IN THE SAME?? Please advise.

SuperCoder Answered Wed 19th of September, 2012 12:26:22 PM

Yes, an office visit note requires 'assessment'(along with plan of care)in which physician mentions the status of the disease during f/u; whether the problem is resolving, improving or worsening. This is also helpful for the federal auditors during auditing to give proper credit for f/u visits.

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