pJohnson15
Networker
One of my providers documents the patient's history like this:
Reason for admission to Swing Bed:
Need for continued IV antibiotics following acute treatment for urosepsis.
Refer to History and Physical for most recent Observation Admission for the following:
1) Chief Complaint
2) History of Present Illness
3) Past Medical History
4) Past Surgical History
5) Home Medications
6) Social History
7) Family History
8) Review of Systems
These notes have a full exam and MDM done.
Correct me if I'm wrong, but this doesn't work for the history portion of the H&P. There is no comment on the ROS or PFSH from the earlier encounter, so I don't believe those count. Does anybody have any thoughts and/or resources that I can give to my provider?
Thank you in advance.
Reason for admission to Swing Bed:
Need for continued IV antibiotics following acute treatment for urosepsis.
Refer to History and Physical for most recent Observation Admission for the following:
1) Chief Complaint
2) History of Present Illness
3) Past Medical History
4) Past Surgical History
5) Home Medications
6) Social History
7) Family History
8) Review of Systems
These notes have a full exam and MDM done.
Correct me if I'm wrong, but this doesn't work for the history portion of the H&P. There is no comment on the ROS or PFSH from the earlier encounter, so I don't believe those count. Does anybody have any thoughts and/or resources that I can give to my provider?
Thank you in advance.