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REDFIELD

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I am auditing a note at provider request and in the Plan portion of the dictated note the physician indicates "I'm going to talk to orthopedics to see....." (and then she elaborated on what her inquiry would be). I questioned if she in fact did contact the ortho office and she said that she had but it was the next day - if she does a handwritten addendum for the chart but references the previous day can I count that as "data reviewed" under the complexity category of the audit tool (for the day before)? I feel since the decision was made to contact Ortho at the actual episode of care it would support pulling the next day's addendum which would carry the response from Ortho. If anyone has a resource, even better. Thank you, Ricci
 
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