Can the SRS be abstracted from a medical chart?
SRS ratings must be rated based on someone’s direct observation of how much supervision the individual receives. However, it is sometimes possible to rate the SRS from records if the records indicate a living situation that strongly implies a specific level of supervision. For example, this is true if the records indicate that the patient lives alone or independently, lives in a nursing home, or lives in a facility in which the rater knows the level of supervision.
Related Questions
- Can a licensed nurse document on a prescription based on a prescription bottle and/or based on the medical chart?
- Does my medical office need Electronic Medical Records, Electronic Health Records and/or Electronic Chart Files?
- Can I leave medical charts on counters or in chart holders outside of examination rooms?
