• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Chief Complaint

N

nyyankees

True Blue
Messages
1,271
Location
Smithtown, NY
Can "patient presents for knee pain.." qualify as a Chief Complaint do does note need to say "chief complaint of knee pain.."?
 
In regard to the knee pain being the CC can/would you use it in the ROS. or another example, CC Shortness of Breath, can that be counted in ROS?
 
As an auditor, as long as there is a ROS, you can count whatever the cc is (knee pain as Musculoskeletal, or SOB as Respiratory) as part of the ROS. There is no need to repeat it. However you can't just take the cc and use it as an ROS element if there is no ROS - that would effectively make it impossible to get a Problem Focused History.

Example to illustrate the point:

cc: f/u of back pain
doing better today, using walker

I would not give this an EPF history (HPI- MF,L, ROS-MK, PFSH-0) I would give this a Problem-Focused History (HPI-L,MF, ROS-0, PFSH-0) However just one system reviewed would make it EPF:

cc: f/u of back pain
doing better today, using walker. Denies falls or pain on exertion.
 
You must log in or register to reply here.
Top