When a pt. is seen in clinic and a decision is made for surgery, should there be a seperate clinic note for the visit in which the decision for surgery was made? The H&P if dictated at the time of the clinical visit becomes part of the surgical package. To be able to charge for the clinical visit do we need to have a seperate clinical note?-
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Wiki Clinic note vs. H&P HELP!
- Thread starter jwertane
- Start date
When a pt. is seen in clinic and a decision is made for surgery, should there be a seperate clinic note for the visit in which the decision for surgery was made? The H&P if dictated at the time of the clinical visit becomes part of the surgical package. To be able to charge for the clinical visit do we need to have a seperate clinical note?FTessaBartels
Guest
You have documentation of a visit
You have documentation of a visit for that date of service. Doesn't matter what you call it.
The documentation ... if it is being dictated as an H&P ... should state:
Date of service: today's date (e.g. 02-28-11)
Date of admission: future date for admission (e.g. 03-04-11)
The note should be filed in BOTH the patient's clinic chart for that date of service, as well as with the hospital record for the admission.
Hope that helps.
F Tessa Bartels, CPC, CEMC
You have documentation of a visit for that date of service. Doesn't matter what you call it.
The documentation ... if it is being dictated as an H&P ... should state:
Date of service: today's date (e.g. 02-28-11)
Date of admission: future date for admission (e.g. 03-04-11)
The note should be filed in BOTH the patient's clinic chart for that date of service, as well as with the hospital record for the admission.
Hope that helps.
F Tessa Bartels, CPC, CEMC