Items in FPM with MESH term: Documentation

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Vaccine Administration: Making the Process More Efficient in Your Practice - Feature

ICD-9 Changes: New Codes of Note - Feature

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

Charting Then and Now - The Last Word

Endometrial Biopsy - Article

ABSTRACT: Endometrial biopsy is an office procedure that serves as a helpful tool in diagnosing various uterine abnormalities. The technique is fairly easy to learn and may be performed without assistance. The biopsy is obtained through the use of an endometrial suction catheter that is inserted through the cervix into the uterine cavity. Twirling the catheter while moving it in and out of the uterine cavity enhances uptake of uterine tissue, which is aspirated into the catheter and removed. Endometrial biopsy is useful in the work-up of abnormal uterine bleeding, cancer screening, endometrial dating and infertility evaluation. Contraindications to the procedure include pregnancy, acute pelvic inflammatory disease, and acute cervical or vaginal infections. Postoperative infection is rare but may be further prevented through the use of prophylactic antibiotic therapy. Intraoperative and postoperative cramping are frequent side effects.

Structure and Synchronicity for Better Charting - Feature

Documenting History in Compliance With Medicare's Guidelines - Feature

Exam Documentation: Charting Within the Guidelines - Feature

Thinking on Paper: Documenting Decision Making - 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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