1997 vs 1995
HISTORY: You should have a patient questionaire that covers all 14 systems, past medical, family and social history. The patient completes this while in the waiting room. The physician reviews, signs and dates it, and then in the patient progress note for that date states any pertinent (positive or negative) and adds "For complete ROS, PFMSH please see the patient questionaire dated dd/mm/yy, reviewed by myself today."
EXAM: Have you considered looking at the 1995 guidelines? For a comprehensive exam you need to cover 8 or more of the 12 organ systems outlines in 1995 guidelines:
Constitutional (Vitals, general appearance)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunological
Your office may be using 1997 guidelines most of the time, but it never hurts to double check a note using the 1995 guidelines.
I know it is really difficult to get to the comprehensive exam for most Ortho specialists.
Laura's suggestion that they consider documenting face-to-face time is good, but ONLY if >50% of the time is spent in counseling/coordination of care.
Good luck. I hope that helps.
F Tessa Bartels, CPC, CEMC