Wiki Can practices share records?

[jojokat]

As a multi-specialty group practice, can outside records/information that is scanned into a patient chart at one practice location be "shared/used" at another practice/provider to obtain missing information? Specifically, the past family, surgical and social history for the patient is part of the records for ENT and the patient is establishing care with a new PCP within the group and this information is missing on his initial visit.

 

[csperoni]

In order to count the PFSH for your visit, your physician would have needed to review/update it, and indicate that it was reviewed (sign/date a patient completed form, or reference in the note it's location & that it was reviewed with any updates). From what you are describing, it does not sound like the new PCP reviewed the PFSH. Just having it in the chart, but the physician not reviewing/updating cannot be counted. Each clinician only gets credit for work personally performed.

 

[SharonCollachi]

Are you asking about the legality of sharing the information? Protected Health Information can be shared for treatment, so you should be good there.

 

[jojokat]

In order to count the PFSH for your visit, your physician would have needed to review/update it, and indicate that it was reviewed (sign/date a patient completed form, or reference in the note it's location & that it was reviewed with any updates). From what you are describing, it does not sound like the new PCP reviewed the PFSH. Just having it in the chart, but the physician not reviewing/updating cannot be counted. Each clinician only gets credit for work personally performed.

Thank you for the clarification. My physician had not reviewed this information as the ROS, PFSH is usually obtained by the ancillary staff but was missed in this instance. I wanted to verify whether or not scanned records in a separate specialty within the same group could be reviewed to obtain the missing information.

 

[csperoni]

Thank you for the clarification. My physician had not reviewed this information as the ROS, PFSH is usually obtained by the ancillary staff but was missed in this instance. I wanted to verify whether or not scanned records in a separate specialty within the same group could be reviewed to obtain the missing information.

If your physician did not review it, you cannot get credit for it in leveling the E/M. Missed is missed. And even when your ancillary staff is obtaining PFSH or ROS, it should still be reviewed (and noted as reviewed) by your physician.
https://www.ama-assn.org/practice-m...staff-who-can-document-components-em-services
Most relevant paragraph from above article:
"Instead, when the information is already documented, billing practitioners can review the information, update or supplement it as necessary, and indicate in the medical record that they have done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (HPI, Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits."