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Patient History Questionaires

  1. #1
    Default Patient History Questionaires
    Medical Coding Books
    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
    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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