Is anyone having issues with this CCDA Validation Result? We keep getting errors: allergies not documented and current medications not documented.
Here is the scenario. Patient had a new patient visit last week. We do a complete note with allergies and meds verified. The next day the patient comes back for a biopsy. We have the biopsy visit type set up as an operative report. The operative report does not have a current meds and allergies section. So say after the biopsy, we want to send out a referral to a specialist or maybe send the consult note from the first visit back to the PCP, this new validation process is looking at the biopsy note because it is the most current visit for the validation.
We are running into the same thing with say sending a referral from a telephone encounter when the last visit was a nurse visit for a lab draw. We don’t verify the meds or allergies again at the nurse visit for the lab draw as the patient was just in and is simply coming back maybe the next day for a fasting lab draw. If we want to send a referral from the telephone encounter, it is looking at the nurse visit and gives the error about allergies and current medications not being validated.
Is there a way to exclude certain visit types so the validation does not look at those types of notes? I’m not finding anything about it in the documentation so I’m thinking no. We want to make sure we are meeting the measures but these are scenarios that we will run into quite frequently. Of course, we can have the nurses start validating meds and allergies for the nurse visits but we don’t have a way around the operative report issue.