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
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