These are general education comment to assist physicians in recording compliant chart notes on patients.
The Chief Complaint: This should be a concise statement from the patient that describes the reason for today's encounter.
The History of Present Illness (HPI) : This consists of a description of the patient's present complaint(s)……..try to include location….quality…..severity…..duration…….timing……context…..modifying factors………..associated signs and symptoms.
The Review of Systems (ROS): This is an inventory of (any/all) body systems, it is obtained by asking the patient a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
The Past/Family/ and/or Social History (PFSH): Past = illnesses, surgeries, injuries and treatments Family = a review of medical events, diseases and hereditary conditions that may place the patient at risk AND Social = includes age appropriate review of past and current activities.
[Interesting note: An ROS or PFSH obtained during an earlier encounter does not need to be re-recorded however it must be noted appropriately as THERE HAS BEEN NO CHANGE IN THE INFORMATION, as well as THE DATE AND LOCATION of the earlier comment.]
In Medical Decision Making (MDM) : for each encounter there should be - an assessment, clinical impression or diagnosis documented which is explicitly stated or implied and easily recognized in the documentation. This also includes comments on test results, old medical record review, orders for diagnostic services, and referrals/consults, or surgical procedures. Comorbidities, underlying diseases, or other factors that increase the complexity of MDM should be noted and described/commented on, as well.
Good documents equal good coding.
The Chief Complaint: This should be a concise statement from the patient that describes the reason for today's encounter.
The History of Present Illness (HPI) : This consists of a description of the patient's present complaint(s)……..try to include location….quality…..severity…..duration…….timing……context…..modifying factors………..associated signs and symptoms.
The Review of Systems (ROS): This is an inventory of (any/all) body systems, it is obtained by asking the patient a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced.
The Past/Family/ and/or Social History (PFSH): Past = illnesses, surgeries, injuries and treatments Family = a review of medical events, diseases and hereditary conditions that may place the patient at risk AND Social = includes age appropriate review of past and current activities.
[Interesting note: An ROS or PFSH obtained during an earlier encounter does not need to be re-recorded however it must be noted appropriately as THERE HAS BEEN NO CHANGE IN THE INFORMATION, as well as THE DATE AND LOCATION of the earlier comment.]
In Medical Decision Making (MDM) : for each encounter there should be - an assessment, clinical impression or diagnosis documented which is explicitly stated or implied and easily recognized in the documentation. This also includes comments on test results, old medical record review, orders for diagnostic services, and referrals/consults, or surgical procedures. Comorbidities, underlying diseases, or other factors that increase the complexity of MDM should be noted and described/commented on, as well.
Good documents equal good coding.
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