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  1. Default Handedness
    Medical Coding Books
    Any input on how you would count "patient is right handed" in the history? I believe it would count as constitutional ROS since it establishes baseline data pertaining to the methods the body uses to function. Especially important if the patient has a "right hand" injury.

    Appreciate your thoughts...

  2. #2
    I would say it is a muscle skeletal element in ROS.

    Just my take,

    Laura, CPC

  3. Default Handedness
    Thanks. Boss isn't going for that one. Says it counts as nothing. Anybody else want to pipe in? I think it should count for something since it is significant.... Help!

  4. #4
    This might be REALLY stretching it... but what about modifying factor? being right handed with a right hand injury certainly modifies your day to day activities. The only thing though is that it doesn't modify the injury, but rather the person. I don't know, this is a good question.

  5. #5
    Milwaukee WI
    Default Can you post the entire history?
    We're operating in the dark ... or at least dusk ... here. Can you post the entire history section?

    F Tessa Bartels, CPC, CEMC

  6. Default
    Patient is a 38 year old male employee of Conagra Foods who complains about his arm which was injured on 01/26/2009 9:30:00 AM.

    Patient states :""Cut with razor knife.""

    Statements above auto populate from electronic data entry by ancillary staff.

    Allergies: No known allergies.. Current Medications:
    Norvasc by: L A D.

    Patient seen immediately due to the emergent nature of the injury. Patient cut his right thumb at work today on a clean, new razor blade knife. The patient is left handed.

    PAST MEDICAL, SOCIAL, FAMILY HISTORY: Noncontributory based upon review of comprehensive questionnaire.

    Current Medications: The medication list was reviewed.
    Allergies: Denies known allergies.
    Immunizations: Not up to date.

    GENERAL: Denies fever, chills and recent weight loss/gain
    CHEST: Denies DOE, cyanosis, wheezing, cough and sputum production.
    CARDIOVASCULAR: Denies chest pain, PND, orthopnea or reduced exercise tolerance.

    Also curious if you would count Chief Complaint/Patient Statement as Chief Complaint since entered by ancillary staff.

  7. #7
    Milwaukee WI
    Default Left Handed
    For HPI:
    QUALITY - Emergent injury
    Location - right thumb
    Context - at work on clean new razor blade
    Modifying factor - patient left handed

    For ROS and PFMSH
    physician states that questionaire is reviewed ... if that section has been completed you have your ROS and PFMSH

    Chief Complaint:
    YES, I'd count it ... you even have a section "PATIENT STATES" - in purest terms the chief complaint is what the patient says is wrong.

    F Tessa Bartels, CPC, CEMC

  8. Default
    "Patient states:" is autopopulated from ancillary staff, not performed by the provider. Does that make a difference?

  9. #9
    Greeley, Colorado
    Quote Originally Posted by Inquisitor View Post
    "Patient states:" is autopopulated from ancillary staff, not performed by the provider. Does that make a difference?
    As long as the HPI is documented by the provider it is ok. You have the "auto-populated" statement and then what appears to be the HPI from the provider.
    Lisa Bledsoe, CPC, CPMA

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