On Fri, 6 Dec 1996, Jim Chamberlain wrote:
> You wrote, in part:
> <<We have elected to document on the same page as the resident and to
> document only the "key elements" of the, history, exam, impression, and
> plan. We not so jokingly call this the four words (e.g. "Fever,
> Non-toxic, Otitis, Amox). We do ask the resident to indicate on the chart
> that we saw the patient. (if we indeed did)>>
> That's as brief as "Rash, Uticaria, Allergy, Benadryl"--don't think it will fly
> as far as being adequate documentation though...
>Jim, interestingly, we didn't think so either but our institution hired
a coding consultant and this guy, in essence, told us that for level 2
type patients the "four words" are OK.
> Jim Chamberlain
> Emergency Department, Room 1450
> Children's National Medical Center
> 111 Michigan Avenue, N.W.
> Washington, DC 20010
> Ofc: (202) 884-3253
> Fax: (202) 884-3573
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