Wiki Need Help with the Audit Form

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jconner0030

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Hello,

I realize that this may be a juvenile question but I am just learning the audit form in my coding class in college. I am looking at the audit from that came out of Carol Bucks 2013 the Next Step. It says it is based off of the 1995 guidelines. I looked at those guidelines and I could not find anything. My question is about the HPI section of the history elements. At the bottom of the history element chart is the table with the history levels. For HPI, it has detailed listed as Extended 4+ and Comprehensive also as 4+. My question is, how do you know when to chose extended, and when to choose comprehensive. I feel like I understand everything else on the audit form but this one part has me stuck. I did order the CEMC study guide in hopes that it would shed some light on the subject. I also ordered the study guide so I can I can become better at Evaluation And Management. Maybe after I get my CPC certification, I can get the CEMC certification. I searched the forum and could not find any information on the subject. I would appreciate any help you could give me. I hope I am making sense.

Thanks,
Jane
 
On that audit form, use the Comprehensive level for the HPI if you have 4+ elements. You can choose the higher of the two levels for this, but keep in mind that for the level of history, all three parts (HPI, ROS, PFSH) need to meet or exceed that level. Also note that if there is no PFSH listed, it applies to both PF and EPF. Use EPF for that one if applicable.

I hope that answers your question, and I am sure you will do fine on the CEMC exam.

Lance
 
Thank you for your feedback. I really appreciate it. I feel like I am missing something. When would you use detailed extended 4+? I am really trying to "get" this information before we have a test on this material.


Thanks,
Jane
 
The terms "detailed" and "comprehensive" refer to the level of the key element of history, not just the HPI component. The HPI will be either "brief" (1-3 items) or "extended" (4+ items). In order for the key element of history to be detailed or comprehensive, the HPI has to be extended, hence the connection between 4+ items and those terms.

As to when you would use "detailed extended 4+" - if either of the other two components of the key element history do not meet the comprehensive level but meet the detailed level, then you would use the column that this falls under. For example, you have 5 HPI items documented, so that meets 4+. However, the ROS has only 8 systems reviewed, so that meets the detailed level. You also have all three PFSH elements, so that is comprehensive. Since the ROS only met the detailed level, the level of history is detailed and the column that was labeled "detailed extended 4+" was used here.

Does this make sense? I hope it helps you. It is a matter of just fully understanding the audit tool.
 
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Thank you. I think it is just going to take practice for me to get it since this is only the second audit form I have filled out. It makes a little more sense now. Again, I appreciate the feedback.

Thank you,
Jane
 
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