HM20 Virtual Conference: Week 3. Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims. Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services CMS in conjunction with the American Medical Association AMA. Two sets of documentation guidelines are in place, referred to as the and guidelines. Increased criticism of the ambiguity in the guidelines from auditors and providers inspired development of the guidelines.
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Pregnancy can be a time of great excitement to the patient, but it can also be a time of danger, and there are certain serious illnesses of pregnancy to be aware of. Much of the history is covered here and documented in notes that the patient is advised to carry at all times. An example can be viewed on the Perinatal Institute website. A good starting point is to ask about number of children the patient has given birth to.
Next, sensitively ask about miscarriages, stillbirths, ectopics and terminations. ART pregnancies are often conceived after a long period of time and after much psychological distress; it is important to be aware of this. In addition, use of ARTs can increase the risk of pre-eclampsia during pregnancy. Gravidity is the total number of pregnancies, regardless of outcome.
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