Wiki medical decision making - I have a question

[JLM929]

I have a question and need some advise. Our office started auditing the providers notes. Our office is EHR so they have templates. under the medical decision making section for the amount and/or complexity of datea reviewed section on the auditing card. can i use 2 points for review and summarization of old records IF my provider put that info in the HPI section or does that HAVE to be in the assestment/plan section? I am not using that info anyway since there is so much information in the HPI section dictated by our provider, so i am not double dipping. Please Help

 

[apollo06]

You may use that info, even though its in the HPI, however the provider should document what records he reviewed and he should have documented a small summary about them, hence the word summarization. A provider cannot just add the documentation that he reviewed/summarized old records. Provider has to be able to reference the auditor to the records if needed to show that there are actual records that he/she reviewed.