Do document the details of the AMA patient encounter in the patient's chart (see samples below). Physicians can further protect themselves by having the patient sign the note. 6 In addition to the discussion with the patient, the . Proper documentation serves many purposes for patients, physicians, nurses and other care providers, and families. Don't use shorthand or abbreviations that aren't widely accepted. Johnson LJ. It is particularly important to document the facts that were conveyed to the patient about the risks of failing to take the recommended action. 10. CPT is a registered trademark of the American Medical Association. Susan Cramer. Roach WH, Jr, Hoban RG, Broccolo BM, Roth AB, Blanchard TP. Login. She likes to see "a robust amount of details . Dental records are especially important when submitting dental benefit claims or responding to lawsuits. When the resident refuses medication: 1. These notes should also comment on the patient's mental status and decision making capacity." Note in the chart any information that will affect either your business or therapeutic relationship. Stay away from words like, "appears to be," "seems to be," or "resting comfortably.". A psychiatrist may be insecure about revealing poor record-keeping habits or, more subtly, may feel discomfort with the notion that reading the chart allows the patient to glimpse into the psychiatrist's mind. Interested in Group Sales? Gender - Female/Male. Pediatrics 2005;115:1428-1431. The gastroenterologist called his friend to remind him to have the test, but the friend refused and said he couldn't make the time. Successful malpractice suits can result even if a patient refused a treatment or test. Charting should include not only changes in status, but what was done about the changes. Create an account to follow your favorite communities and start taking part in conversations. The practice leader should review the number of incomplete charts by clinician each week and monitor the age of those claims. How to Download Child Health Record Forms. For instance, consider a patient whose condition is deteriorating and the nurse charts her observations and discussion with the primary care physician. Answer (1 of 6): Your chart is not for you. The patient had right and left heart catheterization, coronary arteriography, and percutaneous translumenal coronary angioplasty. If the patient persists in the refusal, it is important for the physician to leave the door open for the patient to return. Id say yes but I dont want to assume. Accessed on November 8, 2007. Document all follow-ups with patient and referral practitioner. Without a signature on the medical records the services are not verified and can be considered fraudulent billing. .fl-builder-content *,.fl-builder-content *:before,.fl-builder-content *:after {-webkit-box-sizing: border-box;-moz-box-sizing: border-box;box-sizing: border-box;}.fl-row:before,.fl-row:after,.fl-row-content:before,.fl-row-content:after,.fl-col-group:before,.fl-col-group:after,.fl-col:before,.fl-col:after,.fl-module:before,.fl-module:after,.fl-module-content:before,.fl-module-content:after {display: table;content: " ";}.fl-row:after,.fl-row-content:after,.fl-col-group:after,.fl-col:after,.fl-module:after,.fl-module-content:after {clear: both;}.fl-clear {clear: both;}.fl-clearfix:before,.fl-clearfix:after {display: table;content: " ";}.fl-clearfix:after {clear: both;}.sr-only {position: absolute;width: 1px;height: 1px;padding: 0;overflow: hidden;clip: rect(0,0,0,0);white-space: nowrap;border: 0;}.fl-visible-large,.fl-visible-large-medium,.fl-visible-medium,.fl-visible-medium-mobile,.fl-visible-mobile,.fl-col-group .fl-visible-medium.fl-col,.fl-col-group .fl-visible-medium-mobile.fl-col,.fl-col-group .fl-visible-mobile.fl-col {display: none;}.fl-row,.fl-row-content {margin-left: auto;margin-right: auto;min-width: 0;}.fl-row-content-wrap {position: relative;}.fl-builder-mobile .fl-row-bg-photo .fl-row-content-wrap {background-attachment: scroll;}.fl-row-bg-video,.fl-row-bg-video .fl-row-content,.fl-row-bg-embed,.fl-row-bg-embed .fl-row-content {position: relative;}.fl-row-bg-video .fl-bg-video,.fl-row-bg-embed .fl-bg-embed-code {bottom: 0;left: 0;overflow: hidden;position: absolute;right: 0;top: 0;}.fl-row-bg-video .fl-bg-video video,.fl-row-bg-embed .fl-bg-embed-code video {bottom: 0;left: 0px;max-width: none;position: absolute;right: 0;top: 0px;}.fl-row-bg-video .fl-bg-video iframe,.fl-row-bg-embed .fl-bg-embed-code iframe {pointer-events: none;width: 100vw;height: 56.25vw; max-width: none;min-height: 100vh;min-width: 177.77vh; position: absolute;top: 50%;left: 50%;transform: translate(-50%, -50%);-ms-transform: translate(-50%, -50%); -webkit-transform: translate(-50%, -50%); }.fl-bg-video-fallback {background-position: 50% 50%;background-repeat: no-repeat;background-size: cover;bottom: 0px;left: 0px;position: absolute;right: 0px;top: 0px;}.fl-row-bg-slideshow,.fl-row-bg-slideshow .fl-row-content {position: relative;}.fl-row .fl-bg-slideshow {bottom: 0;left: 0;overflow: hidden;position: absolute;right: 0;top: 0;z-index: 0;}.fl-builder-edit .fl-row .fl-bg-slideshow * {bottom: 0;height: auto !important;left: 0;position: absolute !important;right: 0;top: 0;}.fl-row-bg-overlay .fl-row-content-wrap:after {border-radius: inherit;content: '';display: block;position: absolute;top: 0;right: 0;bottom: 0;left: 0;z-index: 0;}.fl-row-bg-overlay .fl-row-content {position: relative;z-index: 1;}.fl-row-custom-height .fl-row-content-wrap {display: -webkit-box;display: -webkit-flex;display: -ms-flexbox;display: flex;min-height: 100vh;}.fl-row-overlap-top .fl-row-content-wrap {display: -webkit-inline-box;display: -webkit-inline-flex;display: -moz-inline-box;display: -ms-inline-flexbox;display: inline-flex;width: 100%;}.fl-row-custom-height .fl-row-content-wrap {min-height: 0;}.fl-row-full-height .fl-row-content,.fl-row-custom-height .fl-row-content {-webkit-box-flex: 1 1 auto; -moz-box-flex: 1 1 auto;-webkit-flex: 1 1 auto;-ms-flex: 1 1 auto;flex: 1 1 auto;}.fl-row-full-height .fl-row-full-width.fl-row-content,.fl-row-custom-height .fl-row-full-width.fl-row-content {max-width: 100%;width: 100%;}.fl-builder-ie-11 .fl-row.fl-row-full-height:not(.fl-visible-medium):not(.fl-visible-medium-mobile):not(.fl-visible-mobile),.fl-builder-ie-11 .fl-row.fl-row-custom-height:not(.fl-visible-medium):not(.fl-visible-medium-mobile):not(.fl-visible-mobile) {display: flex;flex-direction: column;height: 100%;}.fl-builder-ie-11 .fl-row-full-height .fl-row-content-wrap,.fl-builder-ie-11 .fl-row-custom-height .fl-row-content-wrap {height: auto;}.fl-builder-ie-11 .fl-row-full-height .fl-row-content,.fl-builder-ie-11 .fl-row-custom-height .fl-row-content {flex: 0 0 auto;flex-basis: 100%;margin: 0;}.fl-builder-ie-11 .fl-row-full-height.fl-row-align-top .fl-row-content,.fl-builder-ie-11 .fl-row-full-height.fl-row-align-bottom .fl-row-content,.fl-builder-ie-11 .fl-row-custom-height.fl-row-align-top .fl-row-content,.fl-builder-ie-11 .fl-row-custom-height.fl-row-align-bottom .fl-row-content {margin: 0 auto;}.fl-builder-ie-11 .fl-row-full-height.fl-row-align-center .fl-col-group:not(.fl-col-group-equal-height),.fl-builder-ie-11 .fl-row-custom-height.fl-row-align-center .fl-col-group:not(.fl-col-group-equal-height) {display: flex;align-items: center;justify-content: center;-webkit-align-items: center;-webkit-box-align: center;-webkit-box-pack: center;-webkit-justify-content: center;-ms-flex-align: center;-ms-flex-pack: center;}.fl-row-full-height.fl-row-align-center .fl-row-content-wrap,.fl-row-custom-height.fl-row-align-center .fl-row-content-wrap {align-items: center;justify-content: center;-webkit-align-items: center;-webkit-box-align: center;-webkit-box-pack: center;-webkit-justify-content: center;-ms-flex-align: center;-ms-flex-pack: center;}.fl-row-full-height.fl-row-align-bottom .fl-row-content-wrap,.fl-row-custom-height.fl-row-align-bottom .fl-row-content-wrap {align-items: flex-end;justify-content: flex-end;-webkit-align-items: flex-end;-webkit-justify-content: flex-end;-webkit-box-align: end;-webkit-box-pack: end;-ms-flex-align: end;-ms-flex-pack: end;}.fl-builder-ie-11 .fl-row-full-height.fl-row-align-bottom .fl-row-content-wrap,.fl-builder-ie-11 .fl-row-custom-height.fl-row-align-bottom .fl-row-content-wrap {justify-content: flex-start;-webkit-justify-content: flex-start;}.fl-col-group-equal-height,.fl-col-group-equal-height .fl-col,.fl-col-group-equal-height .fl-col-content{display: -webkit-box;display: -webkit-flex;display: -ms-flexbox;display: flex;}.fl-col-group-equal-height{-webkit-flex-wrap: wrap;-ms-flex-wrap: wrap;flex-wrap: wrap;width: 100%;}.fl-col-group-equal-height.fl-col-group-has-child-loading {-webkit-flex-wrap: nowrap;-ms-flex-wrap: nowrap;flex-wrap: nowrap;}.fl-col-group-equal-height .fl-col,.fl-col-group-equal-height .fl-col-content{-webkit-box-flex: 1 1 auto; -moz-box-flex: 1 1 auto;-webkit-flex: 1 1 auto;-ms-flex: 1 1 auto;flex: 1 1 auto;}.fl-col-group-equal-height .fl-col-content{-webkit-box-orient: vertical; -webkit-box-direction: normal;-webkit-flex-direction: column;-ms-flex-direction: column;flex-direction: column; flex-shrink: 1; min-width: 1px; max-width: 100%;width: 100%;}.fl-col-group-equal-height:before,.fl-col-group-equal-height .fl-col:before,.fl-col-group-equal-height .fl-col-content:before,.fl-col-group-equal-height:after,.fl-col-group-equal-height .fl-col:after,.fl-col-group-equal-height .fl-col-content:after{content: none;}.fl-col-group-nested.fl-col-group-equal-height.fl-col-group-align-top .fl-col-content,.fl-col-group-equal-height.fl-col-group-align-top .fl-col-content {justify-content: flex-start;-webkit-justify-content: flex-start;}.fl-col-group-nested.fl-col-group-equal-height.fl-col-group-align-center .fl-col-content,.fl-col-group-equal-height.fl-col-group-align-center .fl-col-content {align-items: center;justify-content: center;-webkit-align-items: center;-webkit-box-align: center;-webkit-box-pack: center;-webkit-justify-content: center;-ms-flex-align: center;-ms-flex-pack: center;}.fl-col-group-nested.fl-col-group-equal-height.fl-col-group-align-bottom .fl-col-content,.fl-col-group-equal-height.fl-col-group-align-bottom .fl-col-content {justify-content: flex-end;-webkit-justify-content: flex-end;-webkit-box-align: end;-webkit-box-pack: end;-ms-flex-pack: end;}.fl-col-group-equal-height.fl-col-group-align-center .fl-module,.fl-col-group-equal-height.fl-col-group-align-center .fl-col-group {width: 100%;}.fl-builder-ie-11 .fl-col-group-equal-height,.fl-builder-ie-11 .fl-col-group-equal-height .fl-col,.fl-builder-ie-11 .fl-col-group-equal-height .fl-col-content,.fl-builder-ie-11 .fl-col-group-equal-height .fl-module,.fl-col-group-equal-height.fl-col-group-align-center .fl-col-group {min-height: 1px;}.fl-col {float: left;min-height: 1px;}.fl-col-bg-overlay .fl-col-content {position: relative;}.fl-col-bg-overlay .fl-col-content:after {border-radius: inherit;content: '';display: block;position: absolute;top: 0;right: 0;bottom: 0;left: 0;z-index: 0;}.fl-col-bg-overlay .fl-module {position: relative;z-index: 2;}.fl-module img {max-width: 100%;}.fl-builder-module-template {margin: 0 auto;max-width: 1100px;padding: 20px;}.fl-builder-content a.fl-button,.fl-builder-content a.fl-button:visited {border-radius: 4px;-moz-border-radius: 4px;-webkit-border-radius: 4px;display: inline-block;font-size: 16px;font-weight: normal;line-height: 18px;padding: 12px 24px;text-decoration: none;text-shadow: none;}.fl-builder-content .fl-button:hover {text-decoration: none;}.fl-builder-content .fl-button:active {position: relative;top: 1px;}.fl-builder-content .fl-button-width-full .fl-button {display: block;text-align: center;}.fl-builder-content .fl-button-width-custom .fl-button {display: inline-block;text-align: center;max-width: 100%;}.fl-builder-content .fl-button-left {text-align: left;}.fl-builder-content .fl-button-center {text-align: center;}.fl-builder-content .fl-button-right {text-align: right;}.fl-builder-content .fl-button i {font-size: 1.3em;height: auto;margin-right:8px;vertical-align: middle;width: auto;}.fl-builder-content .fl-button i.fl-button-icon-after {margin-left: 8px;margin-right: 0;}.fl-builder-content .fl-button-has-icon .fl-button-text {vertical-align: middle;}.fl-icon-wrap {display: inline-block;}.fl-icon {display: table-cell;vertical-align: middle;}.fl-icon a {text-decoration: none;}.fl-icon i {float: right;height: auto;width: auto;}.fl-icon i:before {border: none !important;height: auto;width: auto;}.fl-icon-text {display: table-cell;text-align: left;padding-left: 15px;vertical-align: middle;}.fl-icon-text-empty {display: none;}.fl-icon-text *:last-child {margin: 0 !important;padding: 0 !important;}.fl-icon-text a {text-decoration: none;}.fl-icon-text span {display: block;}.fl-icon-text span.mce-edit-focus {min-width: 1px;}.fl-photo {line-height: 0;position: relative;}.fl-photo-align-left {text-align: left;}.fl-photo-align-center {text-align: center;}.fl-photo-align-right {text-align: right;}.fl-photo-content {display: inline-block;line-height: 0;position: relative;max-width: 100%;}.fl-photo-img-svg {width: 100%;}.fl-photo-content img {display: inline;height: auto;max-width: 100%;}.fl-photo-crop-circle img {-webkit-border-radius: 100%;-moz-border-radius: 100%;border-radius: 100%;}.fl-photo-caption {font-size: 13px;line-height: 18px;overflow: hidden;text-overflow: ellipsis;}.fl-photo-caption-below {padding-bottom: 20px;padding-top: 10px;}.fl-photo-caption-hover {background: rgba(0,0,0,0.7);bottom: 0;color: #fff;left: 0;opacity: 0;filter: alpha(opacity = 0);padding: 10px 15px;position: absolute;right: 0;-webkit-transition:opacity 0.3s ease-in;-moz-transition:opacity 0.3s ease-in;transition:opacity 0.3s ease-in;}.fl-photo-content:hover .fl-photo-caption-hover {opacity: 100;filter: alpha(opacity = 100);}.fl-builder-pagination,.fl-builder-pagination-load-more {padding: 40px 0;}.fl-builder-pagination ul.page-numbers {list-style: none;margin: 0;padding: 0;text-align: center;}.fl-builder-pagination li {display: inline-block;list-style: none;margin: 0;padding: 0;}.fl-builder-pagination li a.page-numbers,.fl-builder-pagination li span.page-numbers {border: 1px solid #e6e6e6;display: inline-block;padding: 5px 10px;margin: 0 0 5px;}.fl-builder-pagination li a.page-numbers:hover,.fl-builder-pagination li span.current {background: #f5f5f5;text-decoration: none;}.fl-slideshow,.fl-slideshow * {-webkit-box-sizing: content-box;-moz-box-sizing: content-box;box-sizing: content-box;}.fl-slideshow .fl-slideshow-image img {max-width: none !important;}.fl-slideshow-social {line-height: 0 !important;}.fl-slideshow-social * {margin: 0 !important;}.fl-builder-content .bx-wrapper .bx-viewport {background: transparent;border: none;box-shadow: none;-moz-box-shadow: none;-webkit-box-shadow: none;left: 0;}.mfp-wrap button.mfp-arrow,.mfp-wrap button.mfp-arrow:active,.mfp-wrap button.mfp-arrow:hover,.mfp-wrap button.mfp-arrow:focus {background: transparent !important;border: none !important;outline: none;position: absolute;top: 50%;box-shadow: none !important;-moz-box-shadow: none !important;-webkit-box-shadow: none !important;}.mfp-wrap .mfp-close,.mfp-wrap .mfp-close:active,.mfp-wrap .mfp-close:hover,.mfp-wrap .mfp-close:focus {background: transparent !important;border: none !important;outline: none;position: absolute;top: 0;box-shadow: none !important;-moz-box-shadow: none !important;-webkit-box-shadow: none !important;}.admin-bar .mfp-wrap .mfp-close,.admin-bar .mfp-wrap .mfp-close:active,.admin-bar .mfp-wrap .mfp-close:hover,.admin-bar .mfp-wrap .mfp-close:focus {top: 32px!important;}img.mfp-img {padding: 0;}.mfp-counter {display: none;}.mfp-wrap .mfp-preloader.fa {font-size: 30px;}.fl-form-field {margin-bottom: 15px;}.fl-form-field input.fl-form-error {border-color: #DD6420;}.fl-form-error-message {clear: both;color: #DD6420;display: none;padding-top: 8px;font-size: 12px;font-weight: lighter;}.fl-form-button-disabled {opacity: 0.5;}.fl-animation {opacity: 0;}.fl-builder-preview .fl-animation,.fl-builder-edit .fl-animation,.fl-animated {opacity: 1;}.fl-animated {animation-fill-mode: both;-webkit-animation-fill-mode: both;}.fl-button.fl-button-icon-animation i {width: 0 !important;opacity: 0;-ms-filter: "alpha(opacity=0)";transition: all 0.2s ease-out;-webkit-transition: all 0.2s ease-out;}.fl-button.fl-button-icon-animation:hover i {opacity: 1!