Wiki Points for "obtaining history"

[mhstrauss]

In the "general appearance" part of a Physical Exam, one of my docs noted "sleepy and low energy; dazed appearance. Family does most of history". Is this enough to get the 2 points for "obtaining history from someone other than the patient" in the Amount of Data Reviewed? Or does there need to be more detail about exactly which history components were given by the family? This is not mentioned at all in the HPI.

Appreciate any guidance anyone may have, as always! Thanks!

 

[Lashel]

you are talking about the medical decision making portion of history yes? Did your physician document at all what the history was that he got from the family?

Lashel
CPC CPC-I CPPM CEMC

 

[mhstrauss]

you are talking about the medical decision making portion of history yes? Did your physician document at all what the history was that he got from the family?

Lashel
CPC CPC-I CPPM CEMC

He documented a Comprehensive HPI, ROS, and PFSH. He just didn't specify which parts came from the family, and which came from the patient.

 

[MnTwins29]

Figured I would go to the source for this question. It would be appropriate to add the data points in MDM for obtaining this information. Below is the pertinent excerpt from the 1995 Documentation Guidelines (of course, since this is MDM, 1997 would be the same).

- DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.

- DG: Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed” or "additional history obtained from family” without elaboration is insufficient.

 

[mhstrauss]

Thanks for the input!