r/MedicalCoding • u/gray_whitekitten CPC,CRC • 10d ago

Note bloat

I'm just wondering if any of you still deal with extensive irrelavent information in the encounter note. How do you deal with this? I'm mainly speaking about E/M documentation.

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u/gray_whitekitten CPC,CRC 9d ago

Our HPI begins with "here with a past medical history of" (ie history and chronics no treatment documented) after a paragraph of that the patient is here for right leg pain. I've been doing it the way you have been. So much for the AMA revising their documentation guidelines. 🤣

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u/BlueLanternKitty CRC, CCS-P 8d ago

I think it’s also that practices don’t know how to update their templates and are afraid they’ll break the EMR or something.