Notes and billing Flashcards
What are the two main purposes of note-writing in the hospital setting?
- Charting the patient’s history and hospital course for providers to utilize/review
- Charting for billing purposes
True/False.
Besides the basic SOAP format, a lot of the way notes are written and composed comes down to provider style.
True.
True/False.
Providers should avoid both excessive acronym use and also informality in note-writing.
True.
What typically goes in the 1st paragraph of the ‘Subjective’ section of an H&P note for a hospitalized patient?
CC
+
HPI
+
relevant history
What typically goes in the 2nd paragraph of the ‘Subjective’ section of an H&P note for a hospitalized patient?
Targeted RoS findings
(assisting reader in editing their differential)
How many of a patient’s systems must be reviewed/charted in order for a note to maximize its billing potential for RoS?
At least 10
How many of a patient’s systems must be examined/charted in order for a note to maximize its billing potential for physical examination findings?
≥9 systems w/ ≥2 findings each
What typically goes in the ‘Assessment’ portion of an H&P or progress note for a hospitalized patient?
- Very brief summary of situation (can add separate hospital course section if needed); i.e., chief complaint, work-up, and expected disease course
- Can include a second paragraph as a differential
What typically goes in the ‘Plan’ portion of an H&P or progress note for a hospitalized patient?
- A problem-by-problem list of patient diagnoses/problems with associated work-up/management done and to be done
- For most important problems, include a blurb with relevant info.; e.g., differential, physical and lab findings, etc.
What are the 4 ‘D’s that go at the end of an H&P or progress note for a hospitalized patient?
- DNR/directives
- DVT ppx
- Diet
- Dispo planning
