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RE: Physical Exam/Comprehensive
Our chart notes give the doctor the opportunity to check off the systems that they have examined and to note the positive and negative entries. I had hoped that revising the form would help them keep track of the examination critieria. The problem is that they often do not check off all of the systems on the initial exam chart notes, but they later dictate the H & P on a different day then the patient was in the office and on the H & P they do cover the appropriate systems. Keep in mind that the patient has not returned to the office in between the first visit and the surgery. They also do not note on their chart notes that they are doing an H & P for the surgery. My question is can I use the dictated H & P as a criteria for the initial visit exam requirement. I guess my concern is that even though I know that they are using the first visit notes as a guideline the H & P is always dictated just before the surgery and it does not always reflect what they have checked off on the inital notes, and the H & P is also dated a different date then the initial visit.
Thanks,
Dee
Our chart notes give the doctor the opportunity to check off the systems that they have examined and to note the positive and negative entries. I had hoped that revising the form would help them keep track of the examination critieria. The problem is that they often do not check off all of the systems on the initial exam chart notes, but they later dictate the H & P on a different day then the patient was in the office and on the H & P they do cover the appropriate systems. Keep in mind that the patient has not returned to the office in between the first visit and the surgery. They also do not note on their chart notes that they are doing an H & P for the surgery. My question is can I use the dictated H & P as a criteria for the initial visit exam requirement. I guess my concern is that even though I know that they are using the first visit notes as a guideline the H & P is always dictated just before the surgery and it does not always reflect what they have checked off on the inital notes, and the H & P is also dated a different date then the initial visit.
Thanks,
Dee