Forum - Questions & Answers
Multiple Records-One E/M visit
May I use medical records from multiple previous DOS to code E/M services for one specific encounter?
Kidding, right?
No way, unless the doc writes something like "Fam hx from 2010 reviewed, no change"
Clarification
The reason I ask is because it appears that previous E/M notes are cloned into the current visit.
oh
"cloning" is allowed- I can copy and paste the previous Fam Hx, Soc hx, even ROS or HPI into the current note. BUT, and I stress BUT, it must be an active process to bring that part of the note into the current note. So if the EMR automatically copies Soc hx into every note, there is no way to know the doc actually reviewed it. If she has to click a button to import it, that assumes she reviewed the contents and made any appropriate changes.
When I see diabetics, I ask the same questions and get the same responses nearly every time so I copy the previous note and then ask the questions again. If there is a new answer, I change that one. But the key is that I do ask the questions and will testify to that in court, therefore it is acceptable