EM Coding Alert

Caution: Make sure the provider documents review of form.

Going through a patient’s entire past medical, family, and social history can be time consuming and sometimes is like pulling teeth to get the answers you need.

If you can have the patient help by filling out a form before the doctor even enters the room, you can help your providers get a head start on capturing the details you need for the history components of your E/M coding. Try using a form like this one provided by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

NAME:___________________________________________________________________ DATE: _____ / _____ / 20_____

PatientHistory

Requesting/Primary Doctor ______________________________________________________________________________

What is the reason or condition that brings you to our office?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

List all of your medical conditions (i.e. diabetes, heart attack, hypertension, stroke, etc).

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

List all prior surgeries (include date, facility and surgeon):

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

List all medications and dose (aspirin products, herbal, prescription, over the counter, vitamins, etc).

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Allergies to medications? Y N ⇒ Please list:________________________________________

Allergies to IV dyes/x-ray contrast? Y N ⇒ Shellfish or iodine? Y N

Do you smoke tobacco products? Y N ⇒ Packs per day x years:_______________________________

Are you an ex-smoker? Y N ⇒ Packs per day x years:_______________________________

Do you drink alcohol? Y N ⇒ Quantity per week:__________________________________

Occupation:________________________________ Marital Status: S M D W

Significant family medical history?_______________________________________________________________________

Do you require antibiotic prophylaxis prior to medical/dental procedures? Y N

If so, list the medical condition(s):________________________________________________________________________

Date of last menstrual cycle: _____ / _____ / ______ Number of pregnancies:___________________________________

Number of vaginal deliveries:___________________ Cesarean sections:_______________________________________