discussion of case with another healthcare provider

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discussion of case with another healthcare provider

Postby Shoshana » Thu Jun 28, 2018 2:36 pm

My physicians are wanting to document "discussed the patient's care with the nurse" and get credit for Section B of MDM (2 points). They state they should not have to regurgitate what they have already documented in the note and that would be what was discussed with the RN. They are arguing that the note itself is a summarization of what is being done with the patient. Can anyone weigh in on this?
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Shoshana
 
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