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Medical Record Guidelines

hyunck

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Hi Everyone!
We are looking for documentation guidelines regarding how documents should be handled. For example, if the Dr amends a record after the original chart note was created, does a new record need to be sent to the PCP? Does the record sent to the PCP or referring need to include hx's, diagnositcs, etc. or can it only be a brief summary of what the dx was and the treatment plan? Anyone have ideas where we can find these guidelines?
Thanks!
Heather Yunck, CPC
 
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