I tend to follow the more conservative approach that Debra outlined. You either document exactly what the bullet is asking for or you get no credit. OR - you use 1995 guidelines which are much more flexible.
But you've already stated this practice is using 1997 exclusively. Well, they think they are.
Looks like you have some physicians who learned to document under 1995 and think they can use the same verbiage and still get the bullets under 1997.
As to the specifics of your second scenario ... (I think Debra covered the first one)
The bullet for psych is "oriented to time, place and person" ... so the documentation has to either state that in full -or- state "oriented x 3" - no credit for "oriented" all by itself. DOES get a bullet for "appropriate mood and affect"
NOW ... if you are using the 1997 PSYCHIATRIC exam template (vs the general multi-system exam) ... here are the bullets (ALL of which are needed for comprehensive exam)
* Description of speech including: rate; volume; articulation; coherence; and spontaneity with notation of abnormalities
* Description of thought processes, including: rate of thoughts; content of thoughts; abstract reasoning; and computation
* Description of associations
* Description of abnormal or psychotic thoughts including: hallucinations; delusions; preoccupation with violence; homicidal or suicidal ideation; and obsessions
* Description of the patient's judment and insight
Comp[lete Mental Status Exam including:
* Orientation to time, place and person
* Recent and remote memory
* Attention span and concentration
* Language
* Fund of knowledge
* Mood and affect
Hope that helps.
F Tessa Bartels, CPC, CEMC