E/M documentation for physical exam

I was under the impression that an exam (even one done the day of the encounter cannot be referenced if it is located in another part of the written chart.

One of my providers is teeling me he was told he can do that. Please let me know what you think.

re: E/M documentation for physical exam

It can be referenced as long as he documents where it is located in the chart. (ie, see H&P for physical exam dated _____).

re: E/M documentation for physical exam

Where can I find that documented.

re: E/M documentation for physical exam

What document?

If the provider is referring to a document within the chart that includes the physical exam, then the provider should be able to show you where in the chart it is. I was just using "H&P" as an example.

re: E/M documentation for physical exam

Thank you.

re: E/M documentation for physical exam

I know he can reference history, but exam? Exam results can change by the minute! I would say he can refer to it to make a point about something, but I wouldn't think he could get actual credit for that days exam.

UNLESS, it was a very recent exam and he states the same areas/systems were examined and there were no changes to the previously documented exam.

PLUS, the exam should be based on the pesenting problem, so again...it would have to have been a recent exam for the same chief complaint.

There's nothing to adress this in the E&M Guidelines....I'll see if I can't find something credible. I just think this is not a wise shortcut to take!