heatherwinters
Expert
If a nurse calls a patient a couple of days ahead of time to obtain social history, like smoking screening form, that should be documented as a telephone encounter on the date the information is obtained. It would not be documented on the same note as their upcoming visit as if it were obtained the day of the visit correct? Do we have guidlines somewhere the clearly state this? Otherwise it appears as though that work was done the day of the exam, and if the patient no shows, the data disappears as if it were never done at all. If it is part of a telephone encounter it remains in the patient record and can be referred to by the provider in the future. There needs to be a balance between previsit planning efficiency and accurate documentation correct?