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poll/comments: inpatient experiences

Discussion in 'PM&R' started by lucyz02, Apr 7, 2007.

  1. lucyz02

    lucyz02 Junior Member

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    How many have inpatient attendings that have keen sense for scrutiny on all your daily notes with regard to the medicare rules in documentation, ie practically necessay to now write a short story book daily, though not much really has changed.
    Apparently there are certain buzzwords, mentioned or not mentioned you either with points or loose points.
     
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  3. axm397

    axm397 SDN Moderator
    Moderator Physician SDN Advisor

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    we have templates for H&Ps and some check boxes for progress notes to cover most billing issues. we also learn about billing and coding and there's a committee that randomly reviews charts to make sure we are compliant.
     
  4. Louisville04

    Louisville04 Junior Member

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    Yeah it's all about money :eek: . When I used to dictate discharge summaries, it was like all the notes were the same, just the dates changed. I would dictate such irrelevant stuff as "INR was supertherapeutic at 3.0. Therefore coumadin was held" or "patient was constipated. Received fleets enema. Problem resolved" :)

    One of my friends who was an internal medicine resident told me he would start writing his notes out the night before while watching tv and then fill in the blanks when he sees the patient.
     

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