Wiki TCM Documentation

[PennyK]

Can a provider simply state in the patients documentation the patient was admitted thru 12/01/13-12/03/13 or does it have to actually state the patient was admitted on 12/01/13 and discharged on 12/03/13. How technical does the documentation have to be?

 

[Kisalyn]

I would think it's OK. I read it fine as the dates patient was present at the hospital. You can always send the question to your MAC just to make sure. My providers always have in the HPI "admitted on" and "discharged on" date. It's just part of their narrative on the patient's events up to when they present for the office visit.