Wiki ROS

[swelch]

I have an H&P where the patient was admitted through the ED. The H&P physician has referenced the ED report for the review of systems. Can this be counted if I pull the ED report to verify, although it was done by an ED physician ?? Please help.

 

[Chelle-Lynn]

CMS now allows for the chief compliant and history to be pulled from previous documentation. For new and established patients CMS is stating, "that CC and history does not need to be re-entered if it has already been entered by staff of beneficiary." They just need to indicate that they reviewed and verified the information. If the documentation supports the reviewed and verified portion of this new rule, then it would be acceptable as the physician has met the requirements.

Per CMS....

For established patients history and exam, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.

Additionally, CMS is clarifying that for new and established patients chief complaint and history, practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.

 

[swelch]

Yes, thank you, I know this, but does that mean he can use another physicians review of systems? per CMS, it states, ancillary staff or the benficiary. It does not clarify. I have been told in the past that a physician can not refer to another physicians note.