Wiki Review of Old Records

[dballard2004]

In the MDM section points are assigned if the provider reviews old records. One point for the decision to review the records or two points if the records are reviewed and the provider writes a summary of the findings.....

Now my question, I audit charts for the retail clinic setting (among others) and they have clinics in all 50 states, but are linked to the same EMR. For example, if a patient went to the retail clinic in Florida for treatment, and then went to the retail clinic in Utah a few months later, the NP at the Utah clinic can log into the EMR and view the records of the patient's visit to the clinic in Florida. Would this classify as "old records reviewed?" I say that credit should not be givien here because technically these clinics all share the same EMR, it is all one record and they are not really reviewing any old records. They are just reviewing exisiting records in their own system. The providers are giving me some pushback here. Any opinions? Thanks.

 

[dballard2004]

Anyone?

 

[FTessaBartels]

Decision to review

I would count 1 data point for the decision to review old records. Just because it's easier to retrieve them in your case, the provider still had to make the conscious decision to look that information up and review it.

I would not give the 2 data points for review and summarizing old records in this case, because the records are easily visible to anyone in the system.

But, this might partly depend on how complicated the old records are and how much is documented in the "summary" of those old records. Just saying, "Patient was seen in Fla clinic on 11-13-09 with Rx for **** given." doesn't really constitute summarizing old records.

Just my opinion.

F Tessa Bartels, CPC, CEMC

 

[dballard2004]

I would agree with you! Thanks as always.

 

[cknittle]

Review and summarization of old records

Hello- A provider, who performs colonoscopies, is asking for the 2 points for "Review and summarization of old records". He dictates the HPI, ROS, and PFSH in his consult letter back to the requesting provider. The old records are already part of the patients chart because of being seen before for a colonoscopy.

I did not give it to him and I would like more rationale on when to give this credit.
Thanks in advance,

 

[MnTwins29]

Review and summarization

Just one person's opinion here: if the MD includes his observations on the old records, such as "previous records show problems with heart, history of CA,..." , whatever, then I give credit for the summarization, because she or he is adding the parts believed to be significant in the final report, letter to the requesting physician, etc. If the documentation simply says "reviewed old records", then I only give the one point. IMO, it doesn't matter what the summarization contains, as long as there is documentation illustrating what the MD thought was important in the records.

 

[cransom]

What counts as review and summarization

Hi I want to find clear guidelines on what is needed in the MDM when documenting medical records reviewed and summarized. I don't believe just stating reviewed date and has history of high blood pressure is now stable. Do anyone of know if a specific notation or guidelines on what qualifies as a summary

 

[MnTwins29]

Maybe this will help

This spells out documentation requirements for MDM elements, including reviewing old records. While Palmetto is not our MAC, we will use this for guidance.