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At my MTSO, we are penalized if we do NOT include "includes." It has to be typed in Medications and Allergies, PMH, ROS, etc. No one has ever said specifically why, but I would think it's because the word "include" or "includes" covers the you-know-what of the dictator, who is implying that he/she may not have complete information from the patient or whoever gave them the history.
You would not need it in Diagnoses, because the physician/dictator has to take complete responsibility for that section - only one who can diagnose is the MD. |
Includes - mt1313
