Several years ago I spent a couple of hours with our head coder to come up with a macro that would make us “compliant” with all the “points” that billers care about. I don’t remember what “points” are, but I know that when I use this macro I get a lot of RVU’s out of each chart. It’s also helpful for a quick summary at the end.
As with all of these, this is a work in evolution. If you have a way to make this better, please let me know or put it in the comments below.
@AGE@ @SEX@ ***
- ***Laboratory: significant for ***
- ***Radiology: significant for ***
- ***spoke with radiology resident.
- ***I reviewed films myself
- ***EKG: significant for ***
- ***Medical Records: ***significant for ***
- ***Critical Care Time: *** minutes, spent assessing patient, speaking with consultants and family, reviewing results, and outside of procedures
- System at risk: ***
- Consultation: ***
- PMD: @PCP@ ***notified/paged
I have interviewed and examined the patient. I have reviewed and agree with the resident’s History/Physical and Assessment/Plan unless noted as highlights, additions, deletions and/or addendums – see above. Ten ROS performed, unremarkable except as noted.
***Nurse Practitioner Attestation Note
I have seen and examined the patient and have formulated the assessment and plan as documented above.
***Admission: patient’s medical condition, safety or health would be threatened if care was provided in less intensive setting due to: ***
- ***severity of signs and symptoms
- ***potential adverse outcome
- ***unstable condition
- ***need for further diagnostic studies
- ***co-morbidities or extenuating circumstances
- ***failure of outpatient treatment
- event: ***
- with plan to *** and eventual treatment goal of ***.