DecisionHealth, DecisionHealth - 2012 Issue 8 (August)

Template abuses: Be careful using information from previous notes

The problem: Physicians use of template language, “old review of systems [ROS] updated,” on all charts when such an update was not documented correctly or completed for every patient. For example, a doctor refers to her review and changes of a previous visit’s ROS and PFSH in the current note by writing, “ROS from Jan. 5 reviewed and updated.” But the Jan. 5 note does not have the required doctor’s signature and current date on it, says Regan Tyler, senior consultant for DecisionHealth Professional Services.

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