Wiki Obtaining old records

[Mohana Prasad]

In MDM table and under review of data we have1

1)Decision to obtain old records - 1 point.

2) Review of old records - 2 points.

How the above mentioned scenarios will be documented in the report and where it will be found (whether in History or MDM)?

 

[fredabrinson]

There is no mandated place where this info would have to be documented. Usually, you would see the decision to request old records in the Plan, but it could also be in the History. If the physician already had the records from another physician (the patient brought them or they had been mailed prior to the visit), you may see the review and summary with the History or with the Assessment and Plan.

What you need to make sure of is that the info is only counted in one component of the level.

 

[Karolina]

You may find a notation like "Per Dr. ABC's office note/s from (date/s) the patient has .... (issues/treatments/etc)" - this is most likely found in the beginning of the note (history part). Credit 2 points if summarized.
You may see a notation like "we will request the ____report(s) from XYZ-hospital" - this is most likely to appear towards the end (A/P part). Credit 1 point.