NESmith
Expert
Please help with this discussion. I have a Spine Specialist when he does a consult in his dictation he states Past Medical Hx: Has been reviewed and is signed in the patient's chart
Past Surgical Hx: Has been reviewed and is signed in the patient's chart
Family Hx: Has been reviewed and is signed in the patient's chart
Social Hx: Has been reviewed ans is signed in the patient's chart
ROS: has been reviewed and is signed in the patient's chart.
When he states is signed he means the patient has signed the forms. My question is; Is this appropriate documentation for a Level 4 New Patient Consult?
Thanks for your help
Past Surgical Hx: Has been reviewed and is signed in the patient's chart
Family Hx: Has been reviewed and is signed in the patient's chart
Social Hx: Has been reviewed ans is signed in the patient's chart
ROS: has been reviewed and is signed in the patient's chart.
When he states is signed he means the patient has signed the forms. My question is; Is this appropriate documentation for a Level 4 New Patient Consult?
Thanks for your help