Wiki '95/'97 Guidelines: History and MDM

[jkottarathil]

I work in the domiciliary and home setting and I have a question in regarding to obtaining information from the nursing staff. If the provider reaches out to a nursing staff to gain history from them. I count that towards an MDM data point Decision to obtain records and/or history from someone other than patient. I am curious if the information an also be counted towards HPI as an HPI element?

For instance, if the nursing staff says something along the lines of "patient has been experiencing mild back pain for 2 weeks. They had a fall 2 weeks ago." Would this give the provider 1 data point for MDM as well as 3 HPI elements for the history?

Thanks in advance!

 

[mwing124@gmail.com]

Our providers see patients in the domiciliary and home setting as well. We have the statement "history is obtained from patient and facility caregiver (RCC Angelica, care home owner Lesile). Naming who the history is from lets us count one point in data for the E/M leveling.