Valid Chart Documentation?

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AndiJB
Posts: 3
Joined: Fri Aug 01, 2014 1:01 pm

Tue Sep 30, 2014 1:42 pm

I had the opportunity to audit a few charts from a GI practice. I noticed that the chart had a form labeled Progress Notes or Initial Consultation. At best, these forms were used as work sheets with tidbits of information on it to refresh the provider's memory until he dictated the office visit. This dictation is always in the form of a letter back to the referring provider. The letter is the only documentation in the chart of the follow-up visits and initial consultation office visit. The letters do contain some brief HPI, 1-2 system(s) of ROS, initial consult letter contains PFSH. The letter documents an organ system exam, and an opinion/impression is rendered as well as plan for treatment. My question is, can this letter be the sole supporting documentation for billing his services? I have not seen a medical record quite like this before. I have seen handwritten documentation, and I have seen, what I call standard, dictated SOAP notes. I have not seen just a letter as the only documentation of the visit. The letter is signed, however, the chart contains a copy of the letter only, as the original was mailed. Is this letter valid documentation of the visit, if he needed to send medical records to support his billing?
I look forward to your advice and commentary to this scenario.
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admin
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Tue Sep 30, 2014 4:28 pm

We have received your question and sent your question on to our certified auditors and once we receive a response it will be posted here for you.
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admin
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Wed Oct 01, 2014 3:44 pm

Answer provided by NAMAS Team member Sara San Pedro:

If the letter is the report in the record for that encounter, there is nothing that says this is not a valid form of documenting. Some providers will dictate their note in a letter format when they are seeing the patient at the request of another provider.
The level of service and diagnoses should still coincide with the information captured in this letter as it is serving as the documentation.
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