Documentation of History

Once the level of history is determined, documentation of that level of HPI, ROS, and PFSH is accomplished by listing the required number of elements for each of the three components

An ROS and/or PFSH taken during an earlier visit need not be rerecorded if there is evidence that it has been reviewed and any changes to the previous information have been noted. The ROS may be obtained by ancillary staff or may be provided on forms completed by the patient. The clinician must review the ROS, supplement and/or confirm the pertinent positives and negatives, and document the review. By doing so, the clinician takes medical-legal responsibility for the accuracy of the data. If the condition of the patient prevents the clinician from obtaining a history, the clinician should describe the patient’s condition or the circumstances that precluded obtaining the history. Failure to provide and record the required number of elements of the ROS for the level of history designated is the most frequently cited deficiency in audits of clinicians’ mental health records

An ROS and/or PFSH taken during an earlier visit need not be rerecorded if there is evidence that it has been reviewed and any changes to the previous information have been noted. The ROS may be obtained by ancillary staff or may be provided on forms completed by the patient. The clinician must review the ROS, supplement and/or confirm the pertinent positives and negatives, and document the review. By doing so, the clinician takes medical-legal responsibility for the accuracy of the data. If the condition of the patient prevents the clinician from obtaining a history, the clinician should describe the patient’s condition or the circumstances that precluded obtaining the history. Failure to provide and record the required number of elements of the ROS for the level of history designated is the most frequently cited deficiency in audits of clinicians’ mental health records

Determine the Extent of Work in Performing the Examination

The mental status examination of a patient is considered a single system examination.  This definition of what composes a mental status examination was jointly published by the American Medical Association and Health Care Financing Administration (now CMS) in 1997. There are four levels of work associated with performing a mental status examination.

 Failure to provide and record the required number of constitutional elements (including vital signs) is the second most frequently cited deficiency in audits of clinicians’ medical records.

Determine the Complexity of Medical Decision Making 

Medical decision making is the complex task of establishing a diagnosis and selecting treatment and management options. Medical decision making is closely tied to the nature of the presenting problem. A presenting problem is a disease, symptom, sign, finding, complaint, or other reason for the encounter having been initiated.

• Minimal—A problem that may or may not require physician presence, but the services provided are under physician supervision.

• Self-limited or minor—A problem that is transient, runs a definite course, and is unlikely to permanently alter health status. 

• Low severity—A problem of low morbidity, no risk of mortality, and expectation of full recovery with no residual functional incapacity. 

• Moderate severity—A problem with moderate risk of morbidity and/or mortality without treatment, uncertain outcome, and probability of prolonged functional impairment.

• High severity—A problem of high to extreme morbidity without treatment, moderate to high risk of mortality without treatment, and/or probability of severe, prolonged functional impairment.