nyyankees
True Blue
with a young patient (i.e. 2-4 months) how do you capture History (Personal fx, social). I can see family but is it difficukt to get all 3?
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Wiki E/M Levels
- Thread starter nyyankees
- Start date
The 95 and 97 documentation guidelines specifically cover this topic in detail.
Please take a look there and you'll have your answer. I'm on vacation and just thought I'd take a look at the forums.
Please take a look there and you'll have your answer. I'm on vacation and just thought I'd take a look at the forums.
an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.
I hope the above info is helpful.K
I hope the above info is helpful.K
MCCONKEYT
Guest
You helped me too!
Thanks!
Thanks!
Roxanne, step away from the forums....you're on vacation.
Maddismom-
You gave me a good laugh! Lol
You're welcome!
MnTwins29
True Blue
These boards are Roxanne's addiction - she just can't help herself. Do we need to do an intervention??? Or create a 12 step program?