I’m an internal auditor and I have run into some exam documentation that I have not encountered before. The physician is using "denies" within the exam section which to me is more like ROS documentation, not physical exam.
Musculoskeletal:
Wrists Denies swelling, denies tenderness
Ankles Denies swelling, denies tenderness
Feet Denies swelling, denies tenderness
Musculoskeletal:
Wrists Denies swelling, denies tenderness
Ankles Denies swelling, denies tenderness
Feet Denies swelling, denies tenderness
I feel like this could be a potential issue with an outside auditor. Am I completely off base?:confused:
If not, would anyone be able to point me to information I could use to educate the physician?
Thanks!
Hollee Hamilton, CPC, CEMA