Page 16 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

a template can create tunnel vision that makes it easy for the

provider to overlook other significant clinical findings resulting in
a delay in diagnosis or treatment of the actual problem.

Cloned notes may have entries worded exactly like previous

entries, may lack specific individual information, and may give
the appearance that every patient visit details the same exact

problem, the same symptoms, and required the same exact
treatment. If notes are audited by Center for Medicare Services

or a private payor and notes appear to be cloned, this may raise
red flags about whether the actual care was provided to support

the level of coding billed.

Consider the following case:

C A S E S T U DY

A 58-year-old patient with chronic hypertension came to

the office during the busy flu season with complaints of
nausea and the staff selected the “nausea/vomiting”

template. When the physician arrived in the exam room,
he assessed her GI systems, but because the vital signs

were not visible in the portion of the medical record that
was viewed by the physician, the physician didn’t see the

BP of 205/110 recorded by the staff and not mentioned to
the physician. His assessment was lacking any differential

diagnoses or documentation of a medication reconciliation
where it would be discovered that the patient had not

taken her regular medications (including anti-
hypertensives) for three days due to nausea. The physician

prescribed medications for nausea and sent the patient
home. Unfortunately, later that day the patient died from

an intracranial bleed.

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