I have a provider that keeps his notes open for weeks waiting for results from tests. He puts in that he reviewed the results and then closes the note. This doesn’t seem right.
You are correct. This is the way providers used to do their notes when using paper. The chart would stay on their desk until the results came in and were reviewed. Then the chart would go back to medical records.
In today’s world, notes should be signed and closed within 48-72 hours of the encounter. In addition, encounters should not be billed out until the note is completed and signed. For auditing and sending as back up to insurances, the delay between the date of the encounter and when the note is signed can have a negative monetary effect. If the provider is thinking that adding the review of the results will change the coding of the encounter, this is incorrect. An encounter can only be coded for the items that occurred that day, at that encounter, not several days later. The encounter should be coded to include the ordering of the test only. If the provider wants to bring the patient back to the office and review the results, then that new visit note can include the review of the test results and be coded accordingly.
My suggestion is to ask the provider why he’s leaving the note open. Then determine how to achieve this goal and allow the note to be closed (and billed) in a timely manner. This may mean opening a non-billable note, having the patient come back for test results, or setting a deadline for closing notes with or without the test results included.