DecisionHealth, DecisionHealth - 2009 Issue 9 (September)

Ask your providers to clearly document E/M findings and avoid ‘buzzwords'

Review your provider's E/M documentation and watch for overuse of buzzwords such as "unremarkable" or "non-contributory," which don't clearly convey a provider's thoughts or intentions. Auditors also say that using vague phrases too often can indicate a physician is giving a canned answer, such as "see my intake history sheet in my chart, reviewed, no changes."

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