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Thread: Question

  1. #1

    Default Question

    Promo: Code Books
    I have a provider that documented in th exam the following:

    GI-upset w/ Ibuprofen
    Headache w/Skelaxin
    Dry mouth w/Flexeril

    Can all of that count as part of the exam or is it patient history? Thans in advance for anyone's guidance.

  2. #2

    Default

    To me I think this would be more history ... modifying factors.

  3. #3
    Join Date
    Apr 2007
    Location
    Milwaukee WI
    Posts
    4,451

    Default ROS? Past Medical?

    Sounds like a response to "any adverse reactions to drugs?"

    The "side effects" listed don't really seem to be allergic reactions (if they were true allergies you could count as ROS). I'd be inclined to count as Past Medical History.

    F Tessa Bartels, CPC, CEMC

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