A provider can refer back to the ROS on another date of service and/or the Past Family Social History-- BUT he MUST take the reader there. For example,
"ALL ROS has been reviewed from the 11-1-2007 encounter and ALL systems remain unchanged."
The KEY is when you are auditing a note, we have to be able to count how many systems to give them credit for so he/she must say how many they reviewed. If then they also tell you where this information is in the chart (and they actually did review it with the patient) then it becomes billable.
I recommend to all of my physician's that they initial and date the entry they are referring to so that we can prove he/she was actually there reviewing the record- that is not a documentation requirment, but is recommended.
So they can refer back, but they must tell me where they are referring to and what they are referring to. If they do this, then anytime an insuranc carrier request that record, the form or other date of service encounter that has the information they referred to MUST be sent with the current note. Otherwise, the documentation is not complete.
Sorry I rambled on and on.....
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