We just use a standard 1995 guidelines audit tool. We do find that it is a bit easier to meet the exam standards on 1995 in pediatrics than 1997 standards.
We also spend a LOT of time educating physicians about the need for complete histories ... including newborns!
I wish there were some general guideline that would absolve the need for the full ROS for pre-verbal patients (Can you picture the physician asking Mom "have you noticed any signs of depression in your infant?"). But there isn't, so we have to still meet all the guidelines for the level of service.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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