History Issues

 ROS and PFSH may be recorded by others 

 The provider must reference the elements 

 ROS not as easy to obtain from NNs 

 No need to record things in more than one place 

 ROS elements may be documented in the HPI 

 A chief complaint will generally include at least one ROS 

 Chest pain associated with nausea and vomiting 

 HPI element for associated signs/sxs 

 GI ROS element 

 Same statement may not satisfy multiple sub Same statement may not satisfy multiple sub-elements of elements of HPI or ROS 

 Chest pain since this morning can not be both timing and duration

THE “EMERGENCY MEDICINE” CAVEAT

“If the physician is unable to obtain a history from the patient or other source history history from the patient patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.”

CMS History Caveat 

 Documentation must include the Documentation Documentation must include include the reason history is not obtained 

 NH patient with dementia 

 Postictal 

 Severe dyspnea (CHF or Asthma) 

1995 Guidelines for Physical Exam 

  To determine the extent of an examination e the extent of an examination CPT recognizes the following 11 organ systems:  

 Eyes -Psychiatric Psychiatric 

 Cardiovascular Cardiovascular -Respiratory Respiratory 

 Gastrointestinal Gastrointestinal -Genitourinary Genitourinary 

 Musculoskeletal Musculoskeletal -Skin 

 Neurologic 

 Hematologic/Lymphatic/Immunologic 

 Ears, Nose, Mouth and Throat 

 (CMS recognizes constitutional)