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Can someone lead me to a JCAHO or CMS regulation that states a hospital based

outpatient practice needs to have a separate " general summary " form other than

in the initial evaluation in the patient's chart stating medical history,

surgical history, and medications?

I would also like to see the same type of regulation for documentation of a

" learning needs assessment " if someone knows of that as well.

Thanks!

Trevor Huffman P.T., M.S., S.C.S., A.T.,C.

ville, IL 62650

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