Hospital H&P and consult documentation


Olathe, KS
Best answers
I work for 3 general surgeons. One of my docs does not like to write in pt's charts, he dictates everything. That said, my dilema is this: He will dictate a hospital H & P for a surgery he is going to do in 3 weeks to a month and in the pt's chart at our office he just writes, "See Hospital H&P." Then he wants to charge a consult. I know that this is incorrect documentation but am having a VERY hard time explaining to him that he has to dictate a letter to the requesting physician and that the H&P must have the same date on it as the consult charges we submit. I have looked on the American College of Surgeons website for help and even called them but they just confused me even more than I already am. Can someone please help me with this? I desperately need to find something to give this doctor IN WRITING that says he cannot use the H&P for his consult dictation. HELP!:confused:
Our local CMS carrier (NHIC) has a nicely written E&M documentation guidelines manual that spells out these issues very nicely. Check with your carrier, it's likely that they have the same.
Pam Brooks, PCS, CPC
What does the H&P actually say?

What does the H&P actually say? Did he dictate that he is seeing the patient in consultation for x problem at request of PMD? Did he use the date of service of the office consult visit? (e.g. date of service 10-22-08 / date of admission 11-08-08) Did he request a copy sent to the requesting physician? (Our hospital's dictation system allows this to happen.) If a copy isn't being sent automatically can your doc at least dictate a short - "Dear requesting doc ... thanks for consult ... surgery is scheduled, please see attached dictation for details." (and then attach the dictated note)

I understand your frustration. I also understand that the physician doesn't want to have to dictate all the information a second time. That being said, however, I'm willing to bet that the hospital still requires him to review and update the 3-week-old H&P (our hospital wants an H&P completed no earlier than 48 hours prior to admission).

If you don't have access to the hospital record to get a print-out of the dictation ... do what you have to to get that access! You absolutely have to have that information in order to make a final determination of what can be billed.

Good luck

F Tessa Bartels, CPC, CPC-E/M
Last edited: