How much documentation of negatives does HCFA require?
All positive findings must be described. Negative findings do not need to be
individually documented except as appropriate for patient care. A notation
indicating a system was negative is sufficient. The name of each system
reviewed must be documented.
Acceptable:
"Pulmonary: cough x 4 weeks, otherwise negative"
"Cardiac: negative"
"ROS: Cardiac, pulmonary, GI, GU, endocrine all negative"
Unacceptable:
"ROS: negative"
"Pulmonary: positive"
"All systems negative"
This tip is excerpted from a recent issue of The Green Sheet, a newsletter on compensation and reimbursement for nurse practitioners, published monthly by the Law Office of Carolyn Buppert.
Subscriptions: $25 per year (12 issues), mailed first class. To receive The Green Sheet every month, mail your name, address and a check for $25 to Law Offices of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403.
