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Documenting History

  1. #1
    Grand Junction, CO
    Default Documenting History
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    One of my providers documents the patient's history like this:

    Reason for admission to Swing Bed:
    Need for continued IV antibiotics following acute treatment for urosepsis.

    Refer to History and Physical for most recent Observation Admission for the following:
    1) Chief Complaint
    2) History of Present Illness
    3) Past Medical History
    4) Past Surgical History
    5) Home Medications
    6) Social History
    7) Family History
    8) Review of Systems

    These notes have a full exam and MDM done.

    Correct me if I'm wrong, but this doesn't work for the history portion of the H&P. There is no comment on the ROS or PFSH from the earlier encounter, so I don't believe those count. Does anybody have any thoughts and/or resources that I can give to my provider?

    Thank you in advance.

  2. #2

    I think I will need a bit more information in order to answer your question properly.

    But for starters, every E/M visit should have a History, Examination and Medical Decision Making component. The History component is then split up into History of Present Illness (HPI), Review of Systems (ROS), Past Medical, Family, Social History (PFSH). If the HPI is missing, per CMS current guidelines there is no History component at all.

    Unless the inpatient visit is a Subsequent Visit (could then use Exam and MDM to determine E/M level), this poses a problem unless time is documented as the overriding factor. Time documentation requirements must then be followed.

    I don't think you can refer back to another chart (unless performed on the same day, and then the chart should be specified with date and provider) for the HPI section as this should be an updated section for every visit. I would not accept the provider example statement as a full History section for that visit.

    Hope that helps!
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  3. #3
    Grand Junction, CO
    Thank you for the information. I didn't think these counted, but I wanted to get someone else's take on this.

    These are usually the admitting notes for inpatient or swing bed, and the visit that is being referred to is a previous inpatient/observation admission (not on the same day,) and sometimes done by a different provider. There is no time documented on any of them.

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