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TLafleur67

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I have a provider who sometimes dictates "exam unchanged" from previous visit. I know this won't withstand the weight of an audit. What kind of verbiage can he use (if any) to show he is reviewing the previous visit's note?

Will the below work?
"The exam findings from today's visit are unchanged from MMDDYY visit."
 
Exam cannot be documented in this way. Only the ROS can be documented as unchanged since the visit of dd/mm/yy. The exam must be documented in its entirety for each visit..
 
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