New or Est Problem

jimifetil

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Hello

I'm doing QA for a certain facility and I encounter this situation;

1. They say that if an Est patient comes in with disease know to patient (e.i UTI, URTI, etc) within 3 years this is consider Established problem, worsening even though the provider did not state that the disease is worsening. Is this correct?

2. Another if an Est patient comes in with a chronic disease (e.i Hypertension, Diabetics, COPD etc) or a follow up and the provider makes a referral to other provider with specialty those this count as "New problem, additional workup planned" or "Established problem, worsening"

Please Advise. Thank You
 
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