Intake form

grandmacora

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Our office has a form that the PT fills out which has the history and the ROS on it. My question is can the Doc refer to the form for the history of present illiness. When he dictates he says the history form was signed and reviewed by me today. Can I give him credit for the history of present illiness from the form that was filled out by the PT?? Thanks so much Grandma Cora
 

JDRCPC

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Local Chapter Officer
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BERWICK, PA
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Yes, you can use the pt questionnaire for the ROS but as you state, the doc MUST document that he reviewed the information and comment on pertinent positive findings in the note. He should also document the actual questionnaire (date and initials) and keep the form with the record.
 

jdibble

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Daytona Beach, FL
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Our office has a form that the PT fills out which has the history and the ROS on it. My question is can the Doc refer to the form for the history of present illiness. When he dictates he says the history form was signed and reviewed by me today. Can I give him credit for the history of present illiness from the form that was filled out by the PT?? Thanks so much Grandma Cora

You can only use the ROS and PFSH information from the form. It is correct that he signs and dates the form and states that the form was reviewed by him today, also referring to the location of the form. However, he must dictate a separate HPI (history of the present illness) and include the chief complaint. This information must be dictated by him, separate from any HPI or CC stated by ancillary staff or written on a patient history form.

Hope that helps! :)
 

cathyford

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Local Chapter Officer
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Largo, FL
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Documentation issue

Here is what happened to ME. I was the patient. (self pay)I filled out 13 pages of intake forms for the NP visit. The doctor (Orthopedist) NEVER verbally went over any of my histories, NO ROS, medications, I never stepped on a scal. except for the feet HPI, one vital BP by the MA with a wrist cuff...I had 2 xrays and NP visit 99204 chgd me 343.00. He did not meet 3/3 EM coding components. His documentation looks good but it was all from MY intake forms.. The documentation shows my hgt and wght and BMI...So please share your thoughts?

Thanks in advance,

Cathy Ford BS, CPC
 
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