In my paper charts,if a patient has allergic rhinitis, for example, I write in which allergens they react to; for recently post menopausal women I indicate the date of the final menstrual period; for people with coronary artery disease, I write in whether they've had an MI, when etc...
Also, in my notes, I don't just list problems, I comment on them; if I do that with AC, the problems aren't recognized and the ICD codes don't get transferred to the fee slip.
Does anyone have ways around these problems?
Lisa D