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Clinic note vs. H&P HELP!

  1. Question Clinic note vs. H&P HELP!
    Medical Coding Books
    When a pt. is seen in clinic and a decision is made for surgery, should there be a seperate clinic note for the visit in which the decision for surgery was made? The H&P if dictated at the time of the clinical visit becomes part of the surgical package. To be able to charge for the clinical visit do we need to have a seperate clinical note?

  2. #2
    Milwaukee WI
    Default You have documentation of a visit
    You have documentation of a visit for that date of service. Doesn't matter what you call it.
    The documentation ... if it is being dictated as an H&P ... should state:
    Date of service: today's date (e.g. 02-28-11)
    Date of admission: future date for admission (e.g. 03-04-11)

    The note should be filed in BOTH the patient's clinic chart for that date of service, as well as with the hospital record for the admission.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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