Wiki Does this count?

[efuhrmann]

I am having a "discussion" with one of my doctors about documenting a history/physical that was performed but is not a part of our medical record for this patient. I work for a multispecialty clinic and the hospital is across the street. This physician documents "complete history and physical was performed and documented on the hospital chart". His view is that he has access to the hospital info via his personal data base and can retrieve it any time(if an auditor were to ask). I think the H&P should be scanned into our records. He wants it in writing that his way is not correct.

 

[FTessaBartels]

H&P is okay in hospital chart

The H&P is part of the patient's hospital chart. There is no requirement that I know of for you to have a copy of it in the patient's office chart. If audited, you would simply have to obtain the records from the hospital charts. If you are performing a routine internal audit, you should request the records from the hospital; our hospitals routinely fax these to us on request at no charge. (Although don't expect same-day service.)

F Tessa Bartels, CPC, CEMC