Wiki Preventive Medicine & Comprehensive History

[JGGBALLEN]

Good Morning and Happy New Year!

Need clarification please

What exactly is considered "COMPREHENSIVE HISTORY" for PMS

1. I consider this as the physician must have documented the review of system (ROS) of at least 10 organ systems. Correct? If not, please clarify!

2. Stating "NEGATIVE" for both PMS and E&M is Unaccepable. Correct? If not, please clarify!

3. Stating "NEGATIVE" for both PMS and E&M and adding "all systems reviewed is negative" to support COMPREHENSIVE/COMPLETE ROS is also unaccepable. CORRECT? If not, please clarify!

4. In addition to the required ROS, there should be information for Past, Family AND Social history to support the COMPREHENSIVE history. CORRECT? If not, please clarify!

5. Would a statemtent "Family history is negative" be acceptable?

I am good with what is expected within the Exam & Counseling/Anticipatory/Guidance/Risk Interventions.

thank you for any assisitance you can provide and Happy New Year!

 

[wrightju1]

Remember that Comprehensive for Preventive is not necessarily the same as for other E/M services. It is also age appropriate.

First off if it's Preventive you won't have HPI.

As far as ROS you must address at least one system before you use "all others reviewed and negative". Simply stating "negative" does not address the question. For established patients you can also use interval history stating that there are "no changes in ROS since previous review dated..."

For PFSH for an established patient you only need 2 elements for a complete. Usually you can meet that with Immunizations and/or Medications along with Tobacco use or exposure.

You can use a Patient Questionare to address all of these elements as long as the provider reviews the questionare with the patient and states in the note that they have reviewed it, thus tieing the two documents together.

I would think for a new patient all questions should have specific answers, not general "check the box" answers.