Forum - Questions & Answers
Use of forms in E/M encounter
I have always told my physicians that they need to sign and date any form they use in their evaluation and management encounter and refer to the form in their chart notes. I am using a statement from the guidelines under ROS/PFSH that state that the doctor must verify supplemental information. Does anyone else have a citation that supports this?
Use of forms in E/M encounter
This is the exact wording from the Guidelines:
!DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the
information recorded by others.
So, I would allow a statement like this in the dictation, "The remained of the ROS and PFSH is on the form that the patient filled out today, which I reviewed."
Of course, the form has to be dated, but if the MD references and doesn't sign it, I allow it. I suggest they do both, but as I read the exact wording from the Guidelines, I think either works.