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Medications, Allergies, and Problem List Reviewed.....

  1. Question Medications, Allergies, and Problem List Reviewed.....
    Medical Coding Books
    Hello Everyone! I hope you are all well and enjoying spring. I had a question... Our physicians use an EMR for documentation. They have been trained to write--"Medications, Allergies, and Problem List reviewed"--in their documentation. Our system has a medication list, problem list, and allergy list. Would you give Past Medical History credit for this statement?? THANK YOU!!!

  2. #2
    Yes, I would - if they do state that the items were reviewed and where the info is located.

  3. #3
    Don't forget to reference the date so you can lead the audit trail

  4. #4
    Milwaukee WI
    Default Past Med Hx or ROS
    I would give credit for Past Medical Hx and/or ROS depending on what was documented in the original source being referenced.

    And, AR is right - be sure that the physician references the date of the source documentation.

    F Tessa Bartels, CPC, CEMC

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