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Does anyone know or have documentation that states whether a copy of the clinical visit summary has to be in the chart or whether there just needs to be a statement that one was provided (such as a handout printed, or the ACM document created). We use the ACM, however, it is having a moment the last couple of weeks, and the last couple of days it isn't attaching the summaries to the document that shows the summary was created. We are still able to print the paper copy if requested (it goes to a PDF file) or it sends it electronically if the patient is registered on the portal. I am thinking we are not required to keep the copy of the summary in the chart, we just do because...... If I didn't have to manually attache several hundred clinical summaries my day would be much happier!
Thoughts? 
Posted : September 11, 2013 9:43 pm
I believe this to be, that we just have to have the documentation in the notes that one was provided. We do not keep a copy in charts.
Cecil Dickey
Prime Care Medical Center
Posted : September 27, 2013 1:13 am
Topic starter
Thanks! We decided to not manually attach the summaries that were not there. Saved me countless hours of work.
Posted : September 29, 2013 11:37 pm
