Documentation, general

July/August 2016 Issue
Five Lessons for Working With a Scribe [Feature]

Documentation personnel can free up physicians during visits to "do what we do best."

March/April 2016 Issue
Getting Your Notes Done on Time [The Last Word]

These seven tips can help you spend less time on charting.

May/June 2015 Issue
ICD-10 Sprains, Strains, and Automobile Accidents [Feature]

Our tour of ICD-10 continues with the minor injury codes you’re likely to use in family medicine.

March/April 2014 Issue
How to Document and Code for Hypertensive Diseases in ICD-10 [Feature]

In ICD-10, hypertension has a limited number of codes that, on the surface, may appear to make coding this condition relatively simple, at least compared to some of the other ICD-10 complexities. There are only nine codes for primary hypertension and five codes for secondary hypertension. However, as is often the case, the devil is in the details. For example, ICD-10 assumes a causal relationship between hypertension and chronic kidney disease, but you must document the relationship between hypertension and heart disease. Additionally, all of the hypertension codes require an additional code if the patient is a current or former tobacco user. If hypertension is secondary to another disease state, code the underlying condition as well as one of the secondary hypertension codes.

January/February 2014 Issue
10 Steps to Preparing Your Office for ICD-10 -- Now [Feature]

ICD-10 will go into effect on Oct. 1, 2014, for services provided on or after that date. The transition to ICD-10 will be significant and requires proper planning and preparation. First steps include obtaining a copy of the ICD-10 code book and orienting yourself to the new code set, which demands greater specificity. While there are programs available to crosswalk ICD-9 codes to ICD-10 codes, the ICD-9 codes must be specific. Practices should identify the most commonly used diagnosis codes and conduct chart reviews to determine whether current documentation will be sufficient to support ICD-10 coding. Both staff and physicians will require ICD-10 education that includes coding cases. Additionally, practices will need to work with their vendors to ensure ICD-10 preparedness, set cash aside or establish a line of credit to prepare for potential reimbursement delays, and establish new coding workflows for the transition period.

November/December 2013 Issue
Getting Ready for ICD-10: How It Will Affect Your Documentation [Feature]

The switch from ICD-9 to ICD-10 will occur on Oct. 14, 2014. As a first step in their preparations, physicians need to understand 1) the basic changes inherent in the ICD-10 system and 2) how those changes drive the need for additional documentation details. Under ICD-10, the number of diagnosis codes increases substantially, allowing for greater specificity in coding. In turn, this requires physicians to be more specific in their documentation. Although the idea of having the number of diagnostic codes expand is unsettling, physicians can handle it. Many of the new codes are combinations of current ICD-9 codes; many additional codes simply specify right, left, or bilateral; and many other codes are for more complex conditions that are rarely seen in primary care. By learning the basics of the ICD-10 coding system, making some adjustments to their current written or dictated documentation, and ensuring that their EHR system can handle the required increased specificity of documentation, physicians can be ready when ICD-10 arrives. The article includes a two-page document that describes how to document diabetes mellitus under ICD-10.

July/August 2013 Issue
Do You Know What Is (or Isn't) in Your Documentation? [Feature]

The author, a certified professional coder, presents three sample progress notes, challenging the reader to code them appropriately and then explaining how the notes appear from the coder's point of view and what codes she believes the notes will support.

July/August 2012 Issue
How to Reduce Your Malpractice Risk [Feature]

A family physician expert in malpractice risk prevention describes strategies for reducing liability exposure using lessons drawn from actual malpractice cases.

March/April 2012 Issue
A Nursing Home Documentation Tool for More Efficient Visits [Feature]

The authors introduce a documentation tool appropriate for nursing home cares. The tool was designed to help residents sift through the complexities of the nursing home resident, and the authors believe that it can be widely used with the same benefit by all practicing family physicians.

July/August 2011 Issue
Structure and Synchronicity for Better Charting [Feature]

The author outlines an approach to the progress note that emphasizes including the rationale for diagnoses and treatment plans in order to make notes better reflect the physician's thought processes.

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