wynonna
True Blue
The consult note has a detailed history of present illness which is brought forward from the initial visit on May 21 and is copy/pasted to all subsequent visits. By detailed I mean 4 points under HPI, 4 under ROS and 2 under PFSH.
This is the history on the consult in question from Date of Service May 22:
Pt resting comfortably, no acute complaints, rhino rocket in place in right nare, left nare with SS/sang oozing, no active bleeding, oropharynx clear.
Would the above be a Expanded problem focused history, Detailed History, or Comprehensive? Assuming there are 4 points under ROS and 2 under PFSH.
How many points in this interim history do you see?
Do we go by Detailed History of present illness which is brought forward from the initial visit on May 21 which is copy-pasted, or by the interim history, "Pt resting comfortably..."?
thank you
This is the history on the consult in question from Date of Service May 22:
Pt resting comfortably, no acute complaints, rhino rocket in place in right nare, left nare with SS/sang oozing, no active bleeding, oropharynx clear.
Would the above be a Expanded problem focused history, Detailed History, or Comprehensive? Assuming there are 4 points under ROS and 2 under PFSH.
How many points in this interim history do you see?
Do we go by Detailed History of present illness which is brought forward from the initial visit on May 21 which is copy-pasted, or by the interim history, "Pt resting comfortably..."?
thank you