Need Assistance
I need specific reference that states a coder as well as CDI cannot go to an office visit or previous encounter to get clinical information such as an H & P for a current encounter (I know there a few exceptions such as AIDS).
This is becoming an issue in the electronic medical record area where physicians are stating it is now one record. They may do their H & P in the office 6 days in advance of admission and just reference in the progress notes (yes we all know surgeons) but not actually import into the hospital encounter. They will do the interval note update but it is not attached to the H & P proper.
Our Rules and Regs address this adequately.
What I need is a reference regarding our coding rules - I have searched and have not located the specific reference.
Thanks for your help.
Shelia Bullock
sabullock@umc.edu
This is becoming an issue in the electronic medical record area where physicians are stating it is now one record. They may do their H & P in the office 6 days in advance of admission and just reference in the progress notes (yes we all know surgeons) but not actually import into the hospital encounter. They will do the interval note update but it is not attached to the H & P proper.
Our Rules and Regs address this adequately.
What I need is a reference regarding our coding rules - I have searched and have not located the specific reference.
Thanks for your help.
Shelia Bullock
sabullock@umc.edu