Rita B. Conley
Guest
Does anyone out there have a recommended book source for EMRs and documentation requirements. As our providers are now using EMR, I want to provide written references related to EMR requirements, because there will inevitably be push-back related to having to still document within the body of the note the PFSH/FOS in support of a "stand alone" note. Presently I teach the providers that they can review and update the separate PFSH/ROS lists, but if they're going to do this, they need to add a point of reference for the reader (i.e. no changes since visit of [date]). I am still recommending that if they're reviewing the PFSH/ROS, that they "import" from those lists into the note, so that it can, indeed, stand alone in support of medical necessity, etc.