Search found 3 matches

by AndiJB
Mon Mar 16, 2015 9:15 am
Forum: Weekly Tip Comments & Discussions
Topic: Z83.511
Replies: 1
Views: 2061

Re: Z83.511

Family history of glaucoma. No doubt a screening visit.
by AndiJB
Tue Sep 30, 2014 1:42 pm
Forum: Medical Auditing Forum
Topic: Valid Chart Documentation?
Replies: 2
Views: 2339

Valid Chart Documentation?

I had the opportunity to audit a few charts from a GI practice. I noticed that the chart had a form labeled Progress Notes or Initial Consultation. At best, these forms were used as work sheets with tidbits of information on it to refresh the provider's memory until he dictated the office visit. Thi...
by AndiJB
Fri Aug 15, 2014 9:55 am
Forum: Medical Auditing Forum
Topic: Documentation of Independent Visualization of Image, ...
Replies: 2
Views: 3442

Documentation of Independent Visualization of Image, ...

When a provider visualizes an EKG or a urine specimen, the results and sign off is made on the order or the EKG strip. What needs to be documented in the EMR visit note regarding the independent visualization of the image, tracing, or specimen?