Some of our ED physicians are just documenting an HPI, ROS, PE, Med, PFShx, and final diagnosis in their notes. The ancillary information flows into the EMR, but they do not document any further information as to the patient’s treatment, care or outcome of the visit, no Progress note or MDM. For the Facility coding, is this enough information? I feel there needs to be a full story of the patient’s visit in their note. If patient is transferred to another facility, there is no mention of that in the note. The physicians feel we can find that somewhere else in the EMR. Any help is appreciated, we just started coding for this group and are struggling. TIA.
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