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.
