Includes
Posted By: mt1313 on 2006-12-07
In Reply to: question..... - FrustratedQA
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.
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