AmandaW
Guru
When guidelines state that something must be stated 'in the patient's record' what exactly does that mean? Does it have to be in a 'progress note', visit note...or can it be in an 'order' for example?
One example could be a consult. Request, Render, Respond....what if the 'request' part is in an order somewhere within the patient's whole record but not in the H&P? Is that ok? Do orders, individual lab entries, additional notes, etc. count as the patient's "record" or just actual visit notes seeing the patient?
One example could be a consult. Request, Render, Respond....what if the 'request' part is in an order somewhere within the patient's whole record but not in the H&P? Is that ok? Do orders, individual lab entries, additional notes, etc. count as the patient's "record" or just actual visit notes seeing the patient?