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Nurse practitioner coding practices in primary care: a retrospective chart review.
- Source :
-
Journal of the American Academy of Nurse Practitioners [J Am Acad Nurse Pract] 2003 May; Vol. 15 (5), pp. 231-6. - Publication Year :
- 2003
-
Abstract
- Purpose: To describe the coding and documentation practices of nurse practitioners (NPs) when using evaluation and management (E & M) codes in an academic primary care center.<br />Data Sources: A randomized retrospective review of ten charts from a nurse-managed primary care clinic affiliated with a midwestern research-intensive university.<br />Conclusion: The findings demonstrate that the documentation in the chart for six of the ten client encounters did not support the E & M codes assigned by the clinicis NPs. Four of these six client encounters were overcoded; the remaining two encounters were undercoded.<br />Implications for Practice: Findings of this study support the need for additional education of NPs in the areas of coding and documentation.
- Subjects :
- Humans
Random Allocation
Retrospective Studies
Forms and Records Control statistics & numerical data
Nurse Practitioners statistics & numerical data
Nursing Records statistics & numerical data
Practice Patterns, Physicians' statistics & numerical data
Primary Health Care statistics & numerical data
Subjects
Details
- Language :
- English
- ISSN :
- 1041-2972
- Volume :
- 15
- Issue :
- 5
- Database :
- MEDLINE
- Journal :
- Journal of the American Academy of Nurse Practitioners
- Publication Type :
- Academic Journal
- Accession number :
- 12800804
- Full Text :
- https://doi.org/10.1111/j.1745-7599.2003.tb00364.x