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A Multiple-Service Rule for E/M Services - Opinion

Exam Documentation: Charting Within the Guidelines - Feature

Thinking on Paper: Documenting Decision Making - Feature

Documentation Tips for Reducing Malpractice Risk - Feature

Using Peer Review for Self-Audits of Medical Record Documentation - Feature

Off the Charts: Teaching Students in Compliance With HCFA Guidelines - Feature

Documentation Guidelines Likely to Change - Medicare Update

Documenting History in Compliance With Medicare's Guidelines - Feature

Structure and Synchronicity for Better Charting - Feature

Evaluation and Treatment of the Acutely Injured Worker - Article

ABSTRACT: Approximately 3 million work-related injuries were reported by private industries in 2011, and primary care physicians provided care for approximately one out of four injured workers. To appropriately individualize the treatment of an injured worker and expedite the return to work process, primary care physicians need to be familiar with the workers’ compensation system and treatment guidelines. Caring for an injured worker begins with a medical history documenting preexisting medical conditions, use of potentially impairing medications and substances, baseline functional status, and psychosocial factors. An understanding of past and current work tasks is critical and can be obtained through patient-completed forms, job analyses, and the patient’s employer. Return to work in some capacity is an important part of the recovery process. It should not be unnecessarily delayed and should be an expected outcome communicated to the patient during the initial visit. Certain medications, such as opioids, may delay the return to work process, and their use should be carefully considered. Accurate and legible documentation is critical and should always include the location, date, time, and mechanism of injury.

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