Initial Visit Documentation Example When Ordering Orthotics

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This is one of KMC University's "Anatomy of..." documentation samples. It is meant to provide an opportunity to see what "good looks like". This documentation sample has the specifics of 2 complaints, and the documentation elements that can justify medical necessity for prescribing functional orthotics. This documentation example is an initial visit of an episode of care. Note how this provider does an excellent job of digging into the chief and secondary complaints in the history, and then, when the hips and feet are examined, realizes that functional orthotics would be prescribed.

The documentation is color-coded to include examples of why the documentation is solid. Review it to see an example of excellent documentation, not only for an initial visit, but also documentation that fully supports the ordering of customized, functional orthotics. It should be noted that this practice verified the patient's orthotic benefit, and read the payer's Medical Review Policy for Orthotics and Prosthetics, to know what diagnoses are approved for customized, functional orthotics. Hence, the related hip complaint and findings and the adult dysfunctional flat foot diagnoses. As you download and review this note example, realize that it is supplied for educational purposes only.

The Anatomy of an Initial New Patient Visit Note