Physician Documentation
Schwelke, Eric
Description
Collection
Title:
Physician Documentation
Creator:
Schwelke, Eric
Date:
5/10/2013
Text:
Hi all:
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
Eric Schwelke CPO LPO Director
Kessler Prosthetic & Orthotic Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201
Success in Motion
Note: The information contained in this message may be
privileged and confidential and protected from
disclosure. If the reader of this message is not the
intended recipient, or an employee or agent responsible
for delivering this message to the intended recipient, you
are hereby notified that any dissemination, distribution
or copying of this communication is strictly prohibited.
If you have received this communication in error, please
notify us immediately by replying to the message and
deleting it from your computer. Thank you.
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
Eric Schwelke CPO LPO Director
Kessler Prosthetic & Orthotic Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201
Success in Motion
Note: The information contained in this message may be
privileged and confidential and protected from
disclosure. If the reader of this message is not the
intended recipient, or an employee or agent responsible
for delivering this message to the intended recipient, you
are hereby notified that any dissemination, distribution
or copying of this communication is strictly prohibited.
If you have received this communication in error, please
notify us immediately by replying to the message and
deleting it from your computer. Thank you.
Citation
Schwelke, Eric, “Physician Documentation,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 23, 2024, https://library.drfop.org/items/show/235163.
