Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims. Show
Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA). 1995, 1997 GuidelinesTwo sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines. While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts. To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation. Elements of HistoryChief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain). History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).” The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.
The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. Each type of history includes some or all of the following elements: Key Components
Contributory Factors
Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors. The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s). The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the history table must be met. A chief complaint is indicated at all levels.
Chief Complaint (CC): A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record. History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements:
Taking a history from a patient is a skill necessary for examinations and afterwards as a practicing doctor, no matter which area you specialise in. It tests both your communication skills as well as your knowledge about what to ask. Specific questions vary depending on what type of history you are taking but if you follow the general framework below you should gain good marks in these stations. This is also a good way to present your history. In practice you may sometimes need to gather a collateral history from a relative, friend or carer. This may be with a child or an adult with impaired mental state. Procedure StepsStep 01Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so. Step 02 - Presenting Complaint (PC)This is what the patient tells you is wrong, for example: chest pain. Step 03 - History of Presenting Complaint (HPC)Gain as much information you can about the specific complaint. Sticking with chest pain as an example you should ask:
The SOCRATES acronym can be used for any type of pain history. Step 04 - Past Medical History (PMH)Gather information about a patients other medical problems (if any). Step 05 - Drug History (DH)Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc. At this point it is a good idea to find out if the patient has any allergies. Step 06 - Family History (FH)Gather some information about the patients family history, e.g diabetes or cardiac history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease. Step 07 - Social History (SH)This is the opportunity to find out a bit more about the patient’s background. Remember to ask about smoking and alcohol. Depending on the PC it may also be pertinent to find out whether the patient drives, e.g. following an MI patient cannot drive for one month. You should also ask the patient if they use any illegal substances, for example: cannabis, cocaine, etc. Also find out who lives with the patient. You may find that they are the carer for an elderly parent or a child and your duty would be to ensure that they are not neglected should your patient be admitted/remain in hospital. Step 08 - Review of Systems (ROS)Gather a short amount of information regarding the other systems in the body that are not covered in your HPC. The above example involves the CVS so you would focus on the others. These are the main systems you should cover:
Please note these are the main areas, however some courses will also teach the addition of other systems such as ENT/ophthalmology. Step 09 - Summary of HistoryComplete your history by reviewing what the patient has told you. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors. You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. A useful acronym for this is ICE [I]deas, [C]oncerns and [E]xpectations. Step 10 - Patient Questions / FeedbackDuring or after taking their history, the patient may have questions that they want to ask you. It is very important that you don’t give them any false information. As such, unless you are absolutely sure of the answer it is best to say that you will ask your seniors about this or that you will go away and get them more information (e.g. leaflets) about what they are asking. These questions aren’t necessarily there to test your knowledge, just that you won’t try and 'blag it'. Step 11When you are happy that you have all of the information you require, and the patient has asked any questions that they may have, you must thank them for their time and say that one of the doctors looking after them will be coming to see them soon. This guide is designed for students and doctors. If you are applying for medical school and would like more information on the UCAT please check out our complete guide and our guide on how to practice for your exam. We've also prepared a UCAT Practice Test to help you prepare for the exam. |