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Completing Notes

The document outlines guidelines for completing medical notes, emphasizing the importance of consistency between the Chief Complaint, HPI, Assessment, and Treatment. It provides steps for creating HPI and Chief Complaint when one is missing, as well as considerations for chronic conditions and medications that should be continued. Additionally, it addresses the organization of diagnoses, the removal of duplicate codes, and the proper arrangement of primary diagnoses.

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julyrod13
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9 views1 page

Completing Notes

The document outlines guidelines for completing medical notes, emphasizing the importance of consistency between the Chief Complaint, HPI, Assessment, and Treatment. It provides steps for creating HPI and Chief Complaint when one is missing, as well as considerations for chronic conditions and medications that should be continued. Additionally, it addresses the organization of diagnoses, the removal of duplicate codes, and the proper arrangement of primary diagnoses.

Uploaded by

julyrod13
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Completing Notes

1. On chart check first and foremost Chief Complaint, HPI, Assessment, and Treatment
matching. All of these must coincide with each other. Meaning if Chief Complaint
mentions cough, then so must HPI and Assessment/Treatment, or if Assessment has
Cough in Dx, then it must be mentioned in HPI/Chief Complaint.
2. If no HPI, then complete a short HPI using the Chief Complaint to the best of your
ability. Create small story. Vice versa if no Chief Complaint, use the HPI to create a small
CC.
3. If no HPI and no Chief Complaint then use the Assessment and Treatment Plan to create
them both.
4. If little to no Assessment and Treatment look to the Medications and Diagnosis patient is
currently on.
5. Chronic Conditions and Medications should always be continued. NOT ALL. We would
not continue 12 medications at the same time. Only continue the most common for
example Diabetes and Hypertension should always be continued in every note no
exceptions.
6. Other diagnosis to consider is Hyperlipidemia, COPD, Chronic Pain Meds, Heart Failure,
CAD etc.
7. After completing CC/HPI/Dx/Tx and Follow Up try to do some clean up around note.
8. Clean up includes looking into how Triage was done. Medical Hx looks good,
Hospitalizations states 6 months, FamHx, Social Hx, etc.
9. Look into anything with an empty
10. Remove any double merging in Examinations _____.or other.
11. If Dx need rearranging please do so. Ex. Primary Dx needs to be main reason for appt
followed by other reasons. Primary Dx must not be Z nor F code. Z Code Primary only
if Annual Physical. Otherwise, Z codes may not be primary. F Codes are for Psych Dx,
as we are not Psych, we may not use as Primary and must change to an R Code. R Codes
are Symptoms. We may use a symptom of a Psych Code as Primary followed by F Code
intended.
12. Erase any double coding. Ex: Z00.00 might appear more than once if they merged a
Physical template or Lab Orders. If there is a treatment plan, copy and paste the wording
on to the code you are going to leave on chart then erase the double code.

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