Wiki Patient History Questionaires

[aguelfi]

I'm looking for documentation regarding pt history questionaires and what is really needed. My doctors dictate every visit. If the doctor dicates what he reviewed verbally w/ the pt is it necessary to still have the pt fill out these forms? The doctors don't believe it's necessary and I really don't know.

 

[FTessaBartels]

Saves dictation time

For most practices using the patient questionnaire saves the doctor dictation time. Typically the physician will dictate something like:
For complete ROS, Past medical, family, and social history see patient questionnaire, completed and reviewed by me today. Pertinent positives are: (and then what ever positive findings there were).

My physician usually asks that I complete the form once per year (not every visit).

Using such a form may ensure that all areas are actually covered, allowing the highest levels for new patients and consults. (Of course, we're assuming the patient actually completes the form ... )

There's no rule that states you MUST use patient questionnaires and if your doctors are really good about documenting the 14-system ROS and full PMFSH then they may not need it.

F Tessa Bartels, CPC, CPC-E/M

 

[aguelfi]

I didn't think there was anything in writing but I would still like to have my pts fill one out. The dr.s don't want it. I try and tell them it's a way to ensure the complete hx if it's reviewed but they don't want to hear anything of it. I hate it when they miss something so simple in their dication when it could have been prevented.
Thanks for the response.