Need something to tell my doc:
New patient present to clinic, my doc DOES perform initial exam and makes decision for surgery.....asks the PA to do H&P (hospital requirement) BUT my doc is not dictating anything he is using the H&P as his dictation for initial visit (which does not even have his signature on it)
This doesn't seem ok to me? The doc needs to make the decision for surgery correct? It seems to me that if the doc does not exam the patient and make decision for surgery then there is no medical necessity for the HP or for the surgery?
Anyone direct towards some documentation guidance on this?
New patient present to clinic, my doc DOES perform initial exam and makes decision for surgery.....asks the PA to do H&P (hospital requirement) BUT my doc is not dictating anything he is using the H&P as his dictation for initial visit (which does not even have his signature on it)
This doesn't seem ok to me? The doc needs to make the decision for surgery correct? It seems to me that if the doc does not exam the patient and make decision for surgery then there is no medical necessity for the HP or for the surgery?
Anyone direct towards some documentation guidance on this?