Purpose
Medical records are required in some circumstances and provide valuable information about child history. Providers are encouraged to request medical records with ROIs and can do so with the support of their referral specialist, or admin.
Procedure
Documenting medical records review:
- More than 8 mins: providers will document the time spent in review in a daily note and apply charges to FSC.
- Less than 8 mins: providers will document the time spent in review in the communication log or in a cummulative FSC note at the end of the month.
- Providers will use the global abbreviation ‘recreview’ in RT notes and edit the text that appears here in red: “Reviewed patient medical records this day, from (pediatrician, hospital, NICU) and relevant information included: (diagnosis, child delay due to..., history of). Information will be used to inform eval and goals, as needed.
- Complete charges tab for time spent with FSC