Bernadette10
Guru
"Patient is here for a prenatal visit. She is G1P0 at 19w5d. She reports nausea has significantly improved and is only having occasional episodes of heartburn. Fetal movement is normal."
I think EPF history:
4 elements of HPI - duration of 19 weeks, associated symptoms of nausea and heartburn, severity of significantly improved, timing of occasional episodes.
1 ROS of GU for the fetal movement (can't count GI because I already counted it as associated symptoms).
1 PFSH for G1, no previous pregnancies.
Is this the only way to count these? There's no way to get a detailed history out of this, is there?
The nurse also did a depression screen as part of the nurse's notes, but this can't be counted as another ROS, can it? "Depression screen PHQ-2 total = 0." The physician didn't mention this anywhere else in his note, and it's documented as part of the nurse's notes when the patient was first seen by the nurse before seeing the physician. If I could count the depression screen as a psych ROS, then I could get a detailed history, but this is not allowed unless the physician also notes it, right? Any help is appreciated, thanks.
I think EPF history:
4 elements of HPI - duration of 19 weeks, associated symptoms of nausea and heartburn, severity of significantly improved, timing of occasional episodes.
1 ROS of GU for the fetal movement (can't count GI because I already counted it as associated symptoms).
1 PFSH for G1, no previous pregnancies.
Is this the only way to count these? There's no way to get a detailed history out of this, is there?
The nurse also did a depression screen as part of the nurse's notes, but this can't be counted as another ROS, can it? "Depression screen PHQ-2 total = 0." The physician didn't mention this anywhere else in his note, and it's documented as part of the nurse's notes when the patient was first seen by the nurse before seeing the physician. If I could count the depression screen as a psych ROS, then I could get a detailed history, but this is not allowed unless the physician also notes it, right? Any help is appreciated, thanks.