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PubMed · 10622939

Here are key revisions to documentation guidelines.

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Abstract

ED reimbursement experts say the new documentation guidelines proposed by the Health Care Financing Administration will be easier to comply with. For a comprehensive history, only five organ systems are required to be reviewed, not 10. Instead of organ systems, the number of physical exam elements now includes individual components of those systems. It will be easier to identify the level of history if the patient is unable to give an adequate history.

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Centers for Medicare and Medicaid Services, U.S.DocumentationDrug Utilization ReviewEmergency Service, HospitalForms and Records ControlGuidelines as TopicInsurance Claim ReportingMedical History TakingPhysical ExaminationPractice Patterns, Physicians'United StatesJournal Article

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1999. Here are key revisions to documentation guidelines.. https://pubmed.ncbi.nlm.nih.gov/10622939/

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Guidelines for guidelines.

Practice guidelines are proliferating in medicine. In addition to methodological problems that cause guidelines to be outdated rapidly, they are plagued by conflicts of interest. They are largely consensus opinions of panels of experts, most of whom are supported by industry. Professional societies, health insurers, Centers for Medicare and Medicaid Services, and dialysis providers also benefit from guidelines. Little attention is paid to the potential for harm to patients, and to the profession of medicine, from the widespread use of guidelines.

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