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This is probably the most often overlooked source of data points for most physicians.  Whenever we see a patient for the first time (in the hospital or in the office), we almost ALWAYS have some old records to review.  This could take the form of some office notes sent over from the referring physician or a review of the old chart when you see a patient in the hospital. 

In order to claim these two data points, you MUST record your findings in the chart after you review the records.  You cannot simply say, "old records reviewed."

In my practice, when I get a renal consult or do an admission, I make a point of dictating a special section in my note, which I call "Review and Summation of Old Records." 

For example :

Review and Summation of Old Records

" I reviewed the patient's chart dating back for the past five years.  He was most recently admitted for a CHF exacerbation about six months ago.  At that time his creatinine was 1.8.  Looking back over previous admissions, his creatinine has been running in the 1.5 to 1.8 range.  There have been no episodes of ARF in the past."



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