Wiki Separate OV note from H&P for SDC

[mgord]

When the physician sees a patient in the office and is planning on doing surgery, should there be a dictated OV note as well as the H&P for the upcoming surgery? Our docs have only been dictating the H&P and not a separate OV note. I believe there should be both because the H&P "belongs" to the hospital even though we cant charge for that admission since its included in the surgery package and we must have documentation to support our charge for the OV. Can anyone direct me to some specific written documentation to supoort this?

 

[Treetoad]

This happens occasionally with our providers. When the provider dictates their clinic note, they state "This note also serves as the H&P for the patient's upcoming surgery". Because of this, there is no need to dictate another note. We are a hospital based practice and share the same record as the hospital.

Hope this helps.