Wiki What is the minimum requirement to support provider "reviewed" in the medical record?

[mashchakmd@gynplus.com]

What is the minimum requirement to support provider "reviewed" for entries that have been made in the medical record by the medical assistant? Is this minimum requirement that
...the provider has read each item aloud to the patient and asked the patient to confirm its accuracy and then has made any needed revisions?
...the provider has asked the patient if there has been any "family history changes", "new allergies", "new medications" or "medication dose changes", and if so, has recorded the needed revisions.
...the provider has quietly viewed the entire list or section, has deemed it acceptable, and has marked it reviewed.

Thank you for any answers or suggestions you can give me. C. Ann Mashchak, CPMA

 

[jkyles]

Hi there, I think marking it reviewed is sufficient, especially since it isn't being counted toward the level.

 

[rdean]

When the physician pulls the lab/image results into the note, should credit be given as reviewed or should they document reviewed and/or any other relevant information? I read the AMA guidelines Analyze the process of using the data as part of the MDM- means to me they should document something relevant. Is there any clarification on copying in results and allowing credit given as reviewed? Thanks in advance

 

[amyjph]

When the physician pulls the lab/image results into the note, should credit be given as reviewed or should they document reviewed and/or any other relevant information? I read the AMA guidelines Analyze the process of using the data as part of the MDM- means to me they should document something relevant. Is there any clarification on copying in results and allowing credit given as reviewed? Thanks in advance

My view is, I would expect to see some indication that they reviewed it like, I reviewed ________ etc etc and ________.
There are plenty of times when this info is simply copy/pasted or auto-populated by the EMR into each and every note with labs from multiple prior visits. That's just noise and how do you know the provider actually read and reviewed that unless they say so? How are they using it for MDM for today's encounter? What is the plan?

 

[rdean]

My view is, I would expect to see some indication that they reviewed it like, I reviewed ________ etc etc and ________.
There are plenty of times when this info is simply copy/pasted or auto-populated by the EMR into each and every note with labs from multiple prior visits. That's just noise and how do you know the provider actually read and reviewed that unless they say so? How are they using it for MDM for today's encounter? What is the plan?

Thank you, I agree. I am just getting push back from manager and wanted to get others opinions or if there is a legal reference to use for supporting my view.