Any suggestions on how I can guide my docs in reporting the necessary documentation in the medical chart? Thank you in advance for any assistance.
DOS: 1/1/2001 Patient XXX:
HX: Patient returns for bilateral shoulder and knee injections. She stated that Dr. XXXX did not want to do her shoulder arthroplasty until the scratches on her forearms are healed. She has a puppy and thin skin and constantly has open wounds.
IMPRESSION: Bilateral cuff tear arthropathy and bilateral knee arthrosis.
PLAN: Each of the four joints was injected with 40 mg. of Kenalog. I will see her back as needed.
Signed by : Dr. XXXX
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Would this documentation pass the test for 4 injections?