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Thread Topic: documentation
Topic Originator: Cheryl
Post Date March 6, 2008 @ 7:07 AM
documentation


Cheryl
March 6, 2008 @ 7:07 AM Reply  |  Email Friend   |  |Print  |  Top

We have a surgeon who is putting a copy of his consultation letter (which includes H&P elements) to the family physician in the chart as his H&P.  Then on a short stay H&P form he writes "see letter", and documents allergies , assessment and plan.  Is this ok, or does he need to write "H&P reviewed, no change in patient status"?.

Lori
April 19, 2008 @ 5:05 PM Reply  |  Email Friend   |  |Print  |  Top

I think your way is definitely better.  However, the doc should at least say what letter and the date of the letter for audit purposes.

F Tessa Bartels
February 12, 2009 @ 12:06 PM Reply  |  Email Friend   |  |Print  |  Top

As long as your hospital is willing to accept that as a legitimate H&P I see nothing wrong with it. It's a nonbillable service for the surgeon, as it is global to the surgery. And definitely ... he should refer to the consultation letter by date, so as to avoid any question.
F Tessa Bartels, CPC, CEMC



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