The documentation for each visit must stand alone. But that doesn't mean that it has to be all documented on one piece of paper. HOWEVER ... the various pieces of paper MUST be tied together to ensure that an auditor will know where the physician (and the auditor) records and/or finds parts of the whole.
For example a clinic has a patient complete a history form while waiting for appointment; then there's the progress note on which the nurse records vitals and the provider writes notes; and finally there's a dictated note! We will typically see something like: "see dictation, and pt hx form dated mm/dd/yy" written on the "clinic note." The provider will use the brief notations on the clinic progress note to do the dictation and will reference the patient history form (by date) in the body of that dictation.
If all your physician is doing for documentation is filling out the patient's form, then I hope the signed and dated form is photocopied and put in the patient's chart as documentation of the visit. If you don't even have a copy of that documentation then you can only go by what IS in the chart.
F Tessa Bartels, CPC, CEMC
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