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Thread: Patient History Questionaires

  1. #1

    Default Patient History Questionaires

    AAPC: Back to School
    I'm looking for documentation regarding pt history questionaires and what is really needed. My doctors dictate every visit. If the doctor dicates what he reviewed verbally w/ the pt is it necessary to still have the pt fill out these forms? The doctors don't believe it's necessary and I really don't know.
    adrianne, cpc

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Saves dictation time

    For most practices using the patient questionnaire saves the doctor dictation time. Typically the physician will dictate something like:
    For complete ROS, Past medical, family, and social history see patient questionnaire, completed and reviewed by me today. Pertinent positives are: (and then what ever positive findings there were).

    My physician usually asks that I complete the form once per year (not every visit).

    Using such a form may ensure that all areas are actually covered, allowing the highest levels for new patients and consults. (Of course, we're assuming the patient actually completes the form ... )

    There's no rule that states you MUST use patient questionnaires and if your doctors are really good about documenting the 14-system ROS and full PMFSH then they may not need it.

    F Tessa Bartels, CPC, CPC-E/M

  3. #3


    I didn't think there was anything in writing but I would still like to have my pts fill one out. The dr.s don't want it. I try and tell them it's a way to ensure the complete hx if it's reviewed but they don't want to hear anything of it. I hate it when they miss something so simple in their dication when it could have been prevented.
    Thanks for the response.
    adrianne, cpc

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