(2) Independent judgment, assessment, and action. Independent judgment
about the patient's care must be used, assessment of the patient's condition must be
made, and one or more of the following must be accomplished:
(3) Medical record documentation. Documentation must be made in the
patient's authorized record of medical treatment. Documentation must include at least the
date, name of clinic, reason for visit, assessment of the patient, description of the
interaction between the patient and the healthcare provider, disposition, and signature of
the provider of care. Repetitive clinic visits to specialty clinics (i.e., physical therapy and
occupational therapy), will not require full documentation as stated above after the initial
visit unless there is a change in the prescribed treatment. There must also be final
documentation upon completion of prescribed treatment. In all instances, a clear and
acceptable audit trail must be maintained.
(4) Classification. Classification of a visit shall not be dependent on the
(a) professional level of the person providing the service (i.e., physician,
nurse, physicians assistant, medical technician/corpsman, or medical specialist),
(b) physical location of the patient, and
(c) technique or methods of providing healthcare service (such as
telephonic or direct patient contact) when the criteria in paragraph e are met.
f. Types of Visits. The following types of visits are reportable when the criteria in
paragraph 1-15e are met.
(1) Inpatient visit. An inpatient visit will be counted for the following situations:
(a) Each time an inpatient is seen within the admitting MTF on a
consultative basis in an outpatient clinic or in the physical examination and standards
section for evaluation of profile changes.