Wiki Proper Documentation

[kimberlydegrazia]

For proper documentation to support a Level 3 established patient, is it acceptable for the physician to dictate "Past medical history, allergies, medications, and review of systems are all essentially the same as my last note from July" and continue on with the physical exam?

 

[mitchellde]

He is only allowed to pull forward the ROS and it must be reference by the exact date and stated as being reviewed with patient.