For billing purposes, you must list individually 12 systems with 2 components each or include a single blanket statement review of systems was performed and like “a comprehensive, 12-point was negative except as mentioned above in the HPI.” Physical Exam: (Include 10 systems with at least 2 points each) Vital Signs (including pain scale if appropriate) General Appearance: Eyes: Ears, Nose, Throat: Neck: Cardiovascular: Respiratory: Chest/Breast: Gastrointestinal (abdominal): (Including Rectal when appropriate) Genitourinary (Male/Female): (when appropriate) Lymphatic: Musculoskeletal: Skin: Neurological: Psychiatric: Laboratories: Imaging/Diagnostics: Include reviewed by (when appropriate) “Personally me…” Include any x-rays, CT scans, other recent radiology studies, EKG interpretation, etc. Assessment/Impression: The assessment and plan are the most important components of your dictation. Everything above here is data collection. This is where you organize your thoughts and demonstrate your knowledge! Your assessment should be a summary of all of the above data, based on the subjective and objective information you have available at the time of admission. Often the Assessment & Plan are the only parts of a dictation that are read by nurses, consultants, etc. If a diagnosis is clear (ie pneumothorax), say that. However, do not diagnose a patient with a condition without it being 100% certain of it, as your dictation will be used in the future for many purposes and the diagnosis you assign your patient will follow them for life. For example, if you are admitting a patient with shortness of breath, you should not diagnose them with COPD without verifying that the patient has had to definitively diagnose COPD. PFT’s If you dictate and the patient turns out to have only pneumonia with no “COPD exacerbation”
For billing purposes, you must list individually 12 systems with 2 components each or include a single blanket statement like “a comprehensive, 12-point review of systems was performed and was negative except as mentioned above in the HPI.” Physical Exam: (Include 10 systems with at least 2 points each) Vital Signs (including pain scale if appropriate) General Appearance: Eyes: Ears, Nose, Throat: Neck: Cardiovascular: Respiratory: Chest/Breast: Gastrointestinal (abdominal): (Including Rectal when appropriate) Genitourinary (Male/Female): (when appropriate) Lymphatic: Musculoskeletal: Skin: Neurological: Psychiatric: Laboratories: Imaging/Diagnostics: Include “Personally reviewed by me…” (when appropriate) Include any x-rays, CT scans, other recent radiology studies, EKG interpretation, etc. Assessment/Impression: The assessment and plan are the most important components of your dictation. Everything above here is data collection. This is where you organize your thoughts and demonstrate your knowledge! Your assessment should be a summary of all of the above data, based on the subjective and objective information you have available at the time of admission. Often the Assessment & Plan are the only parts of a dictation that are read by nurses, consultants, etc. If a diagnosis is clear (ie pneumothorax), say that. However, do not diagnose a patient with a condition without it being 100% certain of it, as your dictation will be used in the future for many purposes and the diagnosis you assign your patient will follow them for life. For example, if you are admitting a patient with shortness of breath, you should not diagnose them with COPD without verifying that the patient has had PFT’s to definitively diagnose COPD. If you dictate “COPD exacerbation” and the patient turns out to have only pneumonia with no
201314_Program_Guidelines_final_62013.docx