The review of systems, if a patient pleats a patient information sheet or, you know, a health history form that you have in the waiting room and sometimes now we have computers in the waiting room and the patients are asked to enter their information there, sometimes maybe patients are even sent a link at home to where they do this when they're at home. And we can review it once they get into the office. Maybe they're asked that we send them forms and they send them back. Any type of form that the patients are completing, the physicians are able to use that information toward their level of service. Read this expert guidance offered by our expert in one of the E M coding conferences to know more.
You want to make certain that it's complete if the patient maybe only completed the first portion and didn’t understand the second or forgot to do it, didn’t have time to do it.
So maybe the patient was seeking the same thing and just maybe skipped portions or maybe didn’t do the back of the form. So you want to make certain that the form is complete. And if it's not complete by the patient, then whoever rooms the patient or the physician, then the provider, somebody should be checking the form, completing the form.
And then if the physician wants to use this toward his level of service, he needs to make certain that he signs and dates the form appropriately. Past family social history elements can also be included in this form. But again, the form should be signed and dated. And you'd want to reference that in your documentation whether you have a dictated note as was the case in this instance or if you have a handwritten note. You'd still want to make certain that you're clearly indicating that you review the form as per evaluation and management documentation guidelines.
Making a statement such as “See patient’s information sheet” doesn’t necessarily give us the clear picture as to whether or not you reviewed that form and completed it and reviewed it with the patient.
So it's important that it doesn’t just say “See the patient’s information sheet” but it also says, “Review the patient’s information sheet” or “See the patient’s information sheet that I reviewed” something along those lines just to clearly tell anybody reading that note what the physician him or herself did during that visit.
Allergies are also under review of systems and we'll talk about that when we get into that component.
But past history is usually always mentioned. So usually, there's surgery, there's prior illness. And in this instance, the prior instance was that she had a rash we don’t know how long ago but she did have a rash.
The social history also usually mentions tobacco use, marital status, alcohol consumption. One of those is usually mentioned. And so, therefore you're on your way to getting a visit that’s a little bit more detailed.
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Let's take a part of that past and social history briefly. Patient denies any prior illnesses. Do you give credit to the physician if the statement that's in the note that says “Patient denies prior illnesses”? And you absolutely should be giving the physician that credit because the question was asked. The physician shouldn't be penalized for seeing a healthy patient.
“Patient is a vegetarian”. This could certainly go to dietary status. And depending on why the patient is being seen, it might be pretty important. And it could even go into context of the history of present illness, again depending on why we're seeing the patient.
Patient is in OTC vitamins. This is a medication. The current medications are not necessarily limited to prescription medications. It can be OTC medication. Maybe the patient is taking aspirin daily, Tylenol, Motrin. They're taking vitamin C, iron, whatever it is. If they don’t need a prescription for it, that doesn’t mean that it's not medication.
Patient has two dogs and a cat. That could go to living arrangements. It may even go to context if we're seeing the patient for an allergy or something to that effect, maybe a breathing issue. It could go and again depending on the context of the visit.
Talking about the patient’s pregnancy history. This could probably go under past history in regard to prior illnesses, surgeries, that kind of thing according to the evaluation and management documentation guidelines.. Sexual history, if you're getting into ten babies, you may want to talk to the patient. But really this is going to past history as far as there are prior illnesses, prior surgeries, maybe even under GU under the review of systems.
Family history, this is the one history that usually gets pushed to the side. Either the statement, “non-contributory” or “unremarkable” gets used or it's just left blank. But this is where you're going to indicate the health of the parents. And if the parents are alive and well, you indicate parents are alive and well.
The health history of siblings and children, family members related to the chief complaints or just general chronic issues of the family should be included here. This is especially relevant when you're dealing with a new patient so that you make certain that you're touching all your basis and getting everything accomplished within your documentation that you need.
If you look at patient is adopted, patient has dementia, patient is adopted, therefore, they don’t know their family history. That's totally appropriate. Patient has dementia and doesn’t recall having a mother. Well, again, there, we're not able to get the family history because the patient is a poor historian.
Our healthcare training expert mentioned in a medical coding basic conference that in both of those instances, you would get the proper credit because you weren't able to ascertain that information. If the family history is negative for any issues, you wouldn't want to just say “family history is negative”. Why would want to say “Family history is negative for any chronic health conditions” or “Positive for only diabetes” or “Patient’s mom and dad are both alive and well” something in there that indicates that you've asked the question, it was medically necessary to do so.
Even in the case of a trauma, if the patient comes in from a car accident or a gunshot wound or stabbing, some family history may be relevant if it's not an emergent issue. And if it is an emergent issue, you can always say because of the emergent nature of the patient’s condition keeping in line with the evaluation and management documentation guidelines. And then you can talk about why you weren't able to obtain the family history or past history, review of systems, any one of those.
But if you do have the time to be able to ask the patient, it might be important to know if there's any bleeding disorders in the family or so that you'll be able to know how appropriately to treat the patient in that acute situation.
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