Wiki Coping and Pasting previous records.

[TLGray]

I am coding for Oncology and my physicians are coping and pasting notes from previous records and putting them under History of Presence of Cancer at the beginning of the chart. When they take it from more than one previous record they do include month and year of the each record. Can I count this as review and summarization of old records? Any advise would be greatly appreciated.

 

[thomas7331]

I am coding for Oncology and my physicians are coping and pasting notes from previous records and putting them under History of Presence of Cancer at the beginning of the chart. When they take it from more than one previous record they do include month and year of the each record. Can I count this as review and summarization of old records? Any advise would be greatly appreciated.

I would not count it toward this category in the MDM. My understanding of the review of old records is that this is used when the provider obtains records from an outside source or from someone other than the patient - I have never used this toward MDM when the provider is accessing the history from their own chart on the patient, which is really what is happening when the provider is bringing forward records by copying and pasting. I would consider it to be PFSH for the history but not points for MDM.