tfischer
Guru
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,
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,