Wiki Help! 96110

[sluke9]

Dr. is doing development screening using ASQ form at preventative visit. The only documentation is the scoring on the final page of the ASQ and in the note the Plan stating ASQ within normal limit. Any thoughts on whether you would consider that to be enough documentation to support the interpretation/report requirement?

 

[lypece]

yes, the result is enough in the note but the scoring page should be scanned in the patient record.

 

[BenCrocker]

I agree, more information in the record is always good. Especially when it's reviewed in the future. I'm sure not every human can remember every small detail weeks if not months after. Every little bit of information to spark the memory helps.