"inadequately controlled" problem

CatchTheWind

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1) My checklist for existing problems states to give 1 problem point for a "resolved, improving, or stable" problem, or 2 points for a "worsening" problem. What if the problem (which is acne) is "inadequately controlled"? Since it is not getting better or worse, the closest of the above descriptions is "stable," but it would seem that the complexity of an inadquately controlled problem would be more like that of a worsening problem, not a stable one. So how many problem points would you give?

2) The HPI notes the medications the patient is taking, but does not document whether any of these has modified the condition. But since the provider's diagnosis states that the condition is "inadequately controlled," can we extrapolate from this that none of the medications has helped, and get a "modifying factor" out of this?
 

ljones88

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Inadequately controlled

1) 2 points. This is one of those pesky grey areas. I agree that if the condition is failing to change as expected, and the dr is going to change something or try some alternative treatment, something needs to change it should get 2 points to capture the work the dr has to do.

2) If the "History" portion does not state the medications that the patient is using (pt prescribed XYZ, but presents with same signs/symptoms, seeks new treatment, etc) then I wouldn't check off "modifying factors". If the medication is listed in the PFSH section, and was reviewed by the dr, I'd give credit to the PFSH section. I actually come across this often: patient prescribed antibiotics, comes back for eval. Dr failed to mention in the History portion that "patient was prescribed XYZ medication and now ears are better, etc," and therefore I don't give them credit for "modifying factors" because it wasn't stated by the dr. If the dr does mention that "patient wasn't using the medication as prescribed", or "was using medication as prescribed but no shows no improvement" (or basically anything remotely close to explaining what the patient has or has not done to seek improvement, I'd give them credit for the "modifying factors".
 
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