Wiki Documentation for MD seeing patients in Hospital

[nancy726]

I am trying to get some clarification on the documentation guidelines for a physician seeing an inpatient for subsequent care. I understand that the physician will be entering an entry in the hospital chart but what about the physician chart? I have always been told that if there isn't any documentation the service never happened. I am trying to find out if the information in the hospital chart would be the only documentation needed and would stand up to an audit for that matter. Any assistance would be greatly appreciated.
Thank you,
Nancy G. Burch Nelson

 

[mhstrauss]

I am trying to get some clarification on the documentation guidelines for a physician seeing an inpatient for subsequent care. I understand that the physician will be entering an entry in the hospital chart but what about the physician chart? I have always been told that if there isn't any documentation the service never happened. I am trying to find out if the information in the hospital chart would be the only documentation needed and would stand up to an audit for that matter. Any assistance would be greatly appreciated.
Thank you,
Nancy G. Burch Nelson

I'm interested in the answer also. Our docs see patients at a local hospital for consults, subsequent care, surgeries, etc. The only documentation we get copies of here in the clinic is H&P's, consults, and op reports...but never for the subsequent care. I questioned it before (to our admin, not on this forum) but never received a clear answer.

 

[LLONGEWAY]

Cpc

As long as the physican documents in the hospital chart signs and dates it you should be fine.

 

[nancy726]

Thank you for your response. However I am still unclear as to how the coder would be able to code from no documentation and how would it stand up in an audit?

 

[LLovett]

You should have access to the hospitals records done by your provider

There is only need to document in one system but if you are billing for it you are required to provide that documentation upon request. How you get that information may vary depending on your relationship with the facility in question though.

In working for a physician owned practice previously we just had a computer that was part of the hospital system and only had access to our providers records so we could pull them ourselves.

You may have to go thru a records request process with the facility if they can't/won't give you direct access.

Laura, CPC, CPMA, CEMC