Wiki Data point "history from someone other than the pt"

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sotero0419

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Just wanted to ask this question and see what others think. For the Peds department in an ED setting would you consider giving one point for the parent providing the history? What about using an interpreter? Everyone in my department seems to think differently one this. Any feedback would be helpful. Thank You in advance.
 
Receiving History from another person

In pediatrics, you are often (not always) receiving the history exclusively from the parent so it would depend on the age and appropriateness of the patient. If you are talking about an infant, no, I would not give credit for receiving history from someone other than the patient because the parent is speaking on the patient's behalf. If the patient was 17 years-old and gave his or her own history and then the provider separately took the history from Mom or Dad then yes I would give additional credit. The interpreter is speaking on behalf of the patient-just another language. While I would most certainly advise my physician to document that I was receiving information via an interpreter (for liability purposes), I would not seek additional credit when trying to decide the level of E&M. Happy Coding! :)
Ann Linton, CPC, CEMC, CUC
 
I agree. The history from the parent depends on the age of the patient. The interpreter is just relaying information so this would definitely not be an instance that I would give 1 credit point for.
 
The way I see it, the parent/interpreter are relaying the patients history not adding anything new.
In other words they are speaking as if they were the patient themselves.
 
Thank You for responding. This is the same point I was trying to make about the parent giving history. I also feel that it shouldn't be counted for a young child as this is what is expected. As far as the interpreter I was able to find an article from Today's Hospitalist saying to count the interpreter as one data point falling under "optaining history from someone other than the patient". Still not sure I agree 100% but I guess both are open for interpretation based on how vague the guidelines are for data points.

Stacey Otero,CPC,CPMA
 
I guess unless you can understand the patient and the interpreter and they both give histories then I can see two point sources. However that could be very rare.
 
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