dcrossman
Networker
Hi Guys!
I'm going to attempt our first self audit and I'm getting caught up in the history portion of the history, exam, mdm. We have our patients fill out a PFSH questionnaire and it also asks if they have now or have ever had a history of... and it includes things like thyroid d/o, ulcers, diabetes, allergies, depression, colon problems, high blood pressure, etc. Our chart form lists the HPI, we have the seperate PFSH that the pt fills out, in addition to one our MA/RN fills out, and then the Exam and the MDM.
My question is- does any of this go towards the review of systems? The physician does his actual exam, but I'm trying to figure out what exactly the ROS in the History portion should be?
And the other part of this is: If my physician reviews 8 systems: Constitutional, Neck/Thyroid, Resp, Cardio, Chest, GI, GU, Psychiatry is that TECHNICALLY 8 systems, even if only 3 of them are pertinent (for example: pt requests permanent sterilization via Essure procedure- pertinent systems are Constitution, GU, and Psychiatry. I question if the 8 system review counts, or if I should be looking at the RELATED systems. Otherwise he could look at everything and level very high for the Exam portion. It seems to me I should be looking at the pertinent systems, not every single one giving him a point. Do you know what I mean?
Self Auditing is hard! I feel like it is variable as to what a person considers relevent. Any thoughts?
I'm going to attempt our first self audit and I'm getting caught up in the history portion of the history, exam, mdm. We have our patients fill out a PFSH questionnaire and it also asks if they have now or have ever had a history of... and it includes things like thyroid d/o, ulcers, diabetes, allergies, depression, colon problems, high blood pressure, etc. Our chart form lists the HPI, we have the seperate PFSH that the pt fills out, in addition to one our MA/RN fills out, and then the Exam and the MDM.
My question is- does any of this go towards the review of systems? The physician does his actual exam, but I'm trying to figure out what exactly the ROS in the History portion should be?
And the other part of this is: If my physician reviews 8 systems: Constitutional, Neck/Thyroid, Resp, Cardio, Chest, GI, GU, Psychiatry is that TECHNICALLY 8 systems, even if only 3 of them are pertinent (for example: pt requests permanent sterilization via Essure procedure- pertinent systems are Constitution, GU, and Psychiatry. I question if the 8 system review counts, or if I should be looking at the RELATED systems. Otherwise he could look at everything and level very high for the Exam portion. It seems to me I should be looking at the pertinent systems, not every single one giving him a point. Do you know what I mean?
Self Auditing is hard! I feel like it is variable as to what a person considers relevent. Any thoughts?