Our doctors are general surgeons and they often make the decision for surgery on the first visit. They do the H & P on that visit (paper records) which is usually dicated just before the surgery, not on the day that they were seen in the office. Sometimes they do not meet all of the critieria on the visit (paper records) for a higher visit, but they later dictate all of the elements on a transcribed H & P which is forwarded to the hospital. My concern is that the date of the dictation and the date of the actual office visit where they did the H & P are not linked, so an auditor may not accept the extra dictation on the H & P because it is not referenced to the first (date) visit.

Does anyone else have this problem?