Wiki E/M documentation

[TheresaH71]

Hi everyone I would appreciate some help on E/M documentation. My Physician is putting the following in his dictations for E/M services. I would like input on whether or not this is acceptable. I do not think it is but wanted other opinions first. If you agree with me that it is not acceptable maybe some help with where to get information showing him this is not acceptable. Thanks in advance.

for his

Past, Family and Social History, Review of systems he is putting

"Reviewed and as noted per the Hospitalists admission note as documented in the chart. "

 

[kdlberg]

1. The provider needs to refer to the date of service of the original note.
2. He needs to note if there have been any changes to the PFSH or ROS, or say "no changes."

These are both in the 1995 guidelines. See page 5: https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/95Docguidelines.pdf