Good afternoon forum,
I had a question regarding reference of a previously documented ROS/PFSH in a shared inpatient chart. For example, the provider uses a consultation template that at the top says:
Review : H&P Notes Subsequent Notes Nursing Flowsheets
Since this is electronic documentation, they check a box.
The provider may or may not add additional ROS or PFSH themselves.
Would this be sufficient documentation to be able to utilize the ROS or PFSH in the H&P admission note or other notes checked off?
As coders we are not to assume, and based on the documentation guidelines by CMS, I believe more documentation specifically stating review and updates is needed.
Any opinions would be greatly appreciated!
Thanks!
I had a question regarding reference of a previously documented ROS/PFSH in a shared inpatient chart. For example, the provider uses a consultation template that at the top says:
Review : H&P Notes Subsequent Notes Nursing Flowsheets
Since this is electronic documentation, they check a box.
The provider may or may not add additional ROS or PFSH themselves.
Would this be sufficient documentation to be able to utilize the ROS or PFSH in the H&P admission note or other notes checked off?
As coders we are not to assume, and based on the documentation guidelines by CMS, I believe more documentation specifically stating review and updates is needed.
Any opinions would be greatly appreciated!
Thanks!