Fun with Documentation - Dr. Sullivan

Documentation = Communication

• Tells the story
• Medico-Legal
• Billing / Compliance
• Reimbursement

Review of Systems Pointers

• "All systems otherwise negative" : can be used, but don't be a cheater! Develop a system that works for you and covers the appropriate amount of systems
• "High Acuity Caveat" : Unresponsive, Intubated, AMS - these count. Language Barrier does not count!!

Wound Repair

• The length drives the billing - But measure it after the wound is closed!
• Layers, Revising the Wound, Contamination? - lead to complexity
• These are not Time-Based codes.  Conscious Sedation is a Time-Based code (need to document start and stop time)

Pitfalls

• Review of systems : Do NOT RUBBER STAMP
• HPI : try to get at least 4 elements
• PMHx, Family Hx, Social History : if you put a pt in OBS you need ALL three!
  
• Medical Decision Making : Reference the reviewed documentation, labs, and images. Document your Ultrasounds!!
  
• Watch your dictation: particularly left vs right

Document integrity is important and defines you as a physician. 
Avoid cloning notes, document what you do and that will suffice.