Hosp consult/admits

When auditing hospital admits/consults, I know that you have to have 3 out of 3 elements- my question is, if my doc sees a patient and doesn't dictated in his notes the ROS system section when asked to see a patient, and I am only being able to pull 2 or 3 systems out of the history, can I assume that he has reviewed the rest of the hospital chart to see the rest of the ROS from admission note or do they have to state this in the note?

I know if it isn't documented then it isn't done, but I thought there might be slightly different rules for hosptial notes as they all share one chart?

No assumption

You assume nothing. CMS allows the regional carriers to make call on unlisted code or subsequent hospital code when documentation does not support 3 required elements. Many are saying its your option, but advise you to use subsequent hospital codes because you will not have an issue if audited (documentation will support 2 of 3). An unlisted code is a reimbursement nightmare.