Do you have to document assessment if you document a plan of care in visit note for estab f/u pt?
We just updated our EMR system and for our remicade infusion patients the template that was formatted allows for the physicians to document the following information:
-indication
-HPI
(NO ROS or PFSH)
(NO PE)
(NO assessment)
-plan of care
I thought that ALL office visit notes required assessment and plan of care. OR ARE THESE TWO 'ASSESSMENT/PLAN' ONE IN THE SAME?? Please advise.