Hello Everyone! I hope you are all well and enjoying spring. I had a question... Our physicians use an EMR for documentation. They have been trained to write--"Medications, Allergies, and Problem List reviewed"--in their documentation. Our system has a medication list, problem list, and allergy list. Would you give Past Medical History credit for this statement?? THANK YOU!!!-
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Wiki Medications, Allergies, and Problem List Reviewed.....
- Thread starter rowejean@hotmail.com
- Start date
Hello Everyone! I hope you are all well and enjoying spring. I had a question... Our physicians use an EMR for documentation. They have been trained to write--"Medications, Allergies, and Problem List reviewed"--in their documentation. Our system has a medication list, problem list, and allergy list. Would you give Past Medical History credit for this statement?? THANK YOU!!!Karolina
Guru
Yes, I would - if they do state that the items were reviewed and where the info is located.
ARCPC9491
True Blue
Don't forget to reference the date so you can lead the audit trail
FTessaBartels
Guest
Past Med Hx or ROS
I would give credit for Past Medical Hx and/or ROS depending on what was documented in the original source being referenced.
And, AR is right - be sure that the physician references the date of the source documentation.
F Tessa Bartels, CPC, CEMC
I would give credit for Past Medical Hx and/or ROS depending on what was documented in the original source being referenced.
And, AR is right - be sure that the physician references the date of the source documentation.
F Tessa Bartels, CPC, CEMC