documentation

For documentation of chart notes with a EMR system, does all the information (ex: ros, allergies, hpi, cc) need to be included in the note or could it be located in a different section (ex: flowsheet in emr). Would this be accepted as a legal document?

documentation

The guidelines aren't specific enough to answer this question with detail. I believe that CMS tells auditors that all of the documentation for a visit doesn't have to be in one place: think of an inpatient record, where notes can be found in the progress notes section, orders, lab, xray results, etc.

If the vitals are always in a certain section, but are labeled with today's date, and that's how the EMR works, that seems okay to me. If it's past medical history, I wouldn't count it without a notation that it was reviewed.

Does that help or not?

documentation

Yes, this does. I haven't found much information. It is such a gray area. The note would still need to be documented in soap format though with all this information on one page

Documentation

There's no requirement for a SOAP format.

Are you having trouble with something in particular?

documentation

no problems