Wiki See History summary sheet for history

[WendyHunter]

I can't find anything on this so I need help . I have a doctor that writes on their consults see History Summary sheet for past history, I have reviewed with patient.

I was taught that in order to use this documentation you need a date of the document listed in the consult. I am now told that this is not the case on a consult.

 

[FTessaBartels]

Best Practice

The best practice would be to reference the document specifically by date. However, if no date is specified, you can assume the "other document" is dated the same as date of service. If you don't find it there, then there is no document referenced.

Hope that helps.

F Tessa Bartels, CPC, CEMC