Wiki Summarization of old records-How much does

[ADV]

How much does a provider need to write to give 2 points for review and summarization of old records? Also, does it need to be relevant to the current visit?
Also, if a physician requests records and no records are found, do they get the 1 point? Examples are below

Example 1

Not relevant diagnosis -
ER record - Patient in ER for CP.
Physician writes - Record reviewed for ER visit for laceration 6 months ago.

For this one, I think they shouldn't get 2 points but 1 for the request. Am I wrong?

Example 2
Relevant diagnosis
ER record - Patient in ER for CP
Physician writes - Records reviewed for ER visit for observation stay for CP 3 months ago.

Is this sufficient?

Example 3 -
No records found
ER record - No prior records found

Do they get 1 point for this?

 

[MCook]

I don't believe either is sufficient per the Documentation Guidelines:

Relevant finding from the review of old records, and/or the receipt of
additional history from the family, caretaker or other source should be
documented. If there is no relevant information beyond that already obtained,
that fact should be documented. A notation of "Old records reviewed" or
"additional history obtained from family" without elaboration is insufficient.

 

[ADV]

Thanks for the reply, Michelle!

Of the 3 examples I gave, do you think any would get the 1 point for the decision to review old records? Or no since the information would not meet this DG: "supplement that obtained from the patient should be documented."?