In addition to the descriptive status, I ask that my physicans expand on any medications that are applicable to that condition. This could become carrier specific for your region, also.
Q-When documenting three chronic or inactive conditions, do I have to do more than mention the conditions?
A-The documentation should show what actions the physician is taking concerning these conditions and how they affect the chief complaint.
Describe the history of the present illness fully and in such a way that the nature of the presenting problem is clear.
The documentation guidelines specify elements that must be recorded about the present illness. Higher-level services require four or more elements or a description of the status of three or more chronic problems.
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