Wiki "Obtain hx from someone other than patient"

[mwing124@gmail.com]

This phrase is in the "Amount and/or Complexity of Data Reviewed" for one point and also for two. It is my understanding the "someone" must be a medical provider to get to that second point. What is the degree the "someone" must have to get to that second point? Is obtaining a patient's history with an LPN enough to get that point in the complexity?

Thank you,
Michelle

 

[Chelle-Lynn]

PerCMS...
Amountand/or Complexity of Data to Be Reviewed
Theamount and/or complexity of data to be reviewed is based on the types ofdiagnostic testing ordered or reviewed. Indications of the amount and/orcomplexity of data being reviewed include:

A decision to obtain and review old medicalrecords and/or obtain history from sources other than the patient (increasesthe amount and complexity of data to be reviewed)
Discussion ofcontradictory or unexpected test results with the physician who performed orinterpreted the test (indicates the complexity of data to be reviewed)
The physician who ordereda test personally reviews the image, tracing, or specimen to supplementinformation from the physician who prepared the test report or interpretation(indicates the complexity of data to be reviewed)

Hereare some important points to keep in mind when documenting amount and/orcomplexity of data to be reviewed. You should document:
· The type of service, if a diagnosticservice is ordered, planned, scheduled, or performed at the time of the E/Mencounter.

• The review of laboratory, radiology, and/or other diagnostic tests. A simple notation such as "WBC elevated" or "Chest x-ray unremarkable" is acceptable. Alternatively, document the review by initialing and dating the report that contains the test results.
• Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient. You should document that there is no relevant information beyond that already obtained, as appropriate. A notation of "Old records reviewed" or "Additional history obtained from family" without elaboration is not sufficient.

· Discussion about results of laboratory,radiology, or other diagnostic tests with the physician who performed orinterpreted the study.
· The direct visualizationand independent interpretation of an image, tracing, or specimen previously orsubsequently interpreted by another physician