Documenting Your Charts For URI’s

Whether your field is in pediatrics, family medicine, allergy or pulmonology, documenting your charts is key to getting the proper reimbursement for your services. For providers in the previously mentioned fields, the diagnosis of Upper Respiratory Infections has become a common theme for obvious reasons (the pandemic). Below are points that must be hit to properly document and bill for your time and services:

Your exam with diagnostics and findings

Document the findings for breathing and how patient tolerated your tests performed in the office. Example:

The patient comes in for difficulty breathing, no fever reported.

Has no history of asthma.

Rapid COVID test results are negative.

You or your nursing staff perform a spirometry. Upon completion, your findings show parameters do not fall within the normal range. Points to hit:

  1. Make sure the values are documented inside the chart, along with your HPI, Family/Social History
  2. Is the patient exposed to cigarette smoke, pets or other outside sources?

Your treatment plan and referrals if applicable

Subscribe to get access

Read more of this content when you subscribe today.

Leave a Reply

%d bloggers like this: