Wiki Cleaning up documentation

[N70QW]

I am trying to fine tune our providers documentation by education and one on one sessions. The question comes up with one provider that uses the patients forms for his documentation. Example: pt comes in for a physical, pt brings in a form like a scout phyiscal or a church physical form or insurance form etc. this provider uses this form as his note with no other documentation or even an indication that he reviewed the note. I am quite sure this is not acceptable but want to make sure before I approach him. He does sign and date the note but doesn't he have to state at the very least the he has reviewed the note or forms?

 

[FTessaBartels]

Documentation on multiple forms

The documentation for each visit must stand alone. But that doesn't mean that it has to be all documented on one piece of paper. HOWEVER ... the various pieces of paper MUST be tied together to ensure that an auditor will know where the physician (and the auditor) records and/or finds parts of the whole.

For example a clinic has a patient complete a history form while waiting for appointment; then there's the progress note on which the nurse records vitals and the provider writes notes; and finally there's a dictated note! We will typically see something like: "see dictation, and pt hx form dated mm/dd/yy" written on the "clinic note." The provider will use the brief notations on the clinic progress note to do the dictation and will reference the patient history form (by date) in the body of that dictation.

If all your physician is doing for documentation is filling out the patient's form, then I hope the signed and dated form is photocopied and put in the patient's chart as documentation of the visit. If you don't even have a copy of that documentation then you can only go by what IS in the chart.

F Tessa Bartels, CPC, CEMC