# Documentation questions



## tfischer (Aug 17, 2010)

I have quite a few questions:

1.) When using the 1995 Examinatino guidelines, do the vitals need to be included to count toward constitutional? Or can they get credit for only mentioning the general appearance?

2.) If the chief complaint is documented separately from the HPI, can you count that toward Location or other elements if they are not listed in the HPI? For Example:

CC: Abdominal Pain

HPI: Patient states she feels better. (this doesn't tell me where the pain is located, so can I use abdominal toward location?)

3.) In the MDM, do you count the problems that the physicians are NOT managing?

4.) When Psychiatric is being used in part of the PFSHx, can I use that toward psych in the review of systems? For example:

*Past Medical History: COPD, emphysema, tremors
*Past surgical : Tubal ligation
Allergies: Ibuprofen
Medications: Tylenol and Codeine
Psychiatric: History of anxiety, posttraumatic stress disorders.


Thank you,


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## PURNIMA (Aug 17, 2010)

Hi Please see my responses highlighted below,

Hope this helps you,

Thank You,

Purnima S



tfischer said:


> I have quite a few questions:
> 
> 1.) When using the 1995 Examinatino guidelines, do the vitals need to be included to count toward constitutional? Or can they get credit for only mentioning the general appearance? -
> Ans: Yes - We count Vitals in Constitutional, as per our hospital coding specifics.[/COLOR]
> ...


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## preserene (Aug 19, 2010)

4) " When Psychiatric is being used in part of the PFSHx, can I use that toward psych in the review of systems? For example:

*Past Medical History: COPD, emphysema, tremors
*Past surgical : Tubal ligation
Allergies: Ibuprofen
Medications: Tylenol and Codeine
Psychiatric: History of anxiety, posttraumatic stress disorders.

Ans: No we dont count ROS from PFSH" From Purnima.

I do not agree with this answer because: for (eg) all these are important for the current case under discussion- Abdominal pain
(Eg) past surgical- Tubal ligation;  this is vitally important to rule out whether she is having Ectopic Pregnancy and may/ might have gone for rupture ectopic, irrespective of knowing her LMP from the history.
Tylenol codeine can produce abdominal pain too (gastritis; even gastric perforation and internal bleeding)
 Psy: history of anxiety ,PTD can also be a cause of abdominal pain with the ANS invovlment.
So also others have impact on the present condition and necessitates ROS related to that.

This just for adding up information regarding the importance of ROS  for the CC, PFSH


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