Wiki documented 'in the pt's record' meaning

[AmandaW]

When guidelines state that something must be stated 'in the patient's record' what exactly does that mean? Does it have to be in a 'progress note', visit note...or can it be in an 'order' for example?

One example could be a consult. Request, Render, Respond....what if the 'request' part is in an order somewhere within the patient's whole record but not in the H&P? Is that ok? Do orders, individual lab entries, additional notes, etc. count as the patient's "record" or just actual visit notes seeing the patient?

 

[Lukelie]

This is a good question. To my knowledge, we see the information in the encounter note. There is a field in our template for consults for referring provider. A colleague of mine said her previous employer required providers to state in the HPI 'patient is referred by Dr.X for consultation for xx'.

 

[MnTwins29]

I look at this question as a PHYSICIAN documentation question - what parts of the record are completed and/or signed by the physician? I would certainly count an order or a consultation as part of the "record." If the physician is ordering a medication or diagnostic test, there must be a reason for this - and if that reason or codition is noted in the order instead of a progress note, why would this NOT be considered "part of the record"? Seeing that Amanda, the poster who asked the question, is a hospitalist coder, I am basing this response on an inpatient hospital patient record.