Concerning the discussion a few days ago about which heading gait testing goes under. - echomt

Gait testing is part of the neurological examination and should therefore go under that heading.  From my perspective, healthcare document integrity should hold sway over account specs or doctor preferences.  Too many doctors think all that matters is what they say or how they interpret what is said, which is total bunk.  If that were true, we would all just start typing melanotic stools every time one of these medical geniuses dictates that because certainly there isn't a doctor anywhere who would not get what that was in reference to.  But we don't just type that because it is incorrect and actually constitutes a medical content error.  We correct it because accurate information accurately stated is more important than doctor preferences or account specs.  The neurological exam is specific and requires a specific approach for specific reasons.  Gait testing is part of the neuroligic exam, and that is the heading under which it should be transcribed regardless of whether the doctor gets it or wants it or likes or not. 

I for one am sick of doing things a certain way just because someone else insists it be done that way regardless of whether it is correct or not.  We either have value in the documentation process or we don't.  I believe we do, and as one who considers myself to be part of the healthcare team and therefore working for the patient, I'm going to do what I know to be correct for the sake of the accuracy of the patient's medical record whether doctors like it or not.  Personally, I would like to see all of us taking this stand for the sake of our profession as well as for the sake of the patients in whose behalf we take part in the healthcare documentation process.  These are legal documents and should reflect that status, which means they should be correctly formatted and contain accurate information that has been accurately stated.

That's my rant.