Legal Tips
Provided by Carolyn Buppert, MSN, JD, ANP

How much documentation of negatives does HCFA require?

All positive findings must be described. Negative findings do not need to be individually documented except as appropriate for patient care. A notation indicating a system was negative is sufficient. The name of each system reviewed must be documented.


"Pulmonary: cough x 4 weeks, otherwise negative"
"Cardiac: negative"
"ROS: Cardiac, pulmonary, GI, GU, endocrine all negative"


"ROS: negative"
"Pulmonary: positive"
"All systems negative"

This tip is excerpted from a recent issue of The Green Sheet, a newsletter on compensation and reimbursement for nurse practitioners, published monthly by the Law Office of Carolyn Buppert.

Subscriptions: $25 per year (12 issues), mailed first class. To receive The Green Sheet every month, mail your name, address and a check for $25 to Law Offices of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403.

Updated October 17, 2000


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