Medical History Documentation
Without a strong foundation, a house will collapse for lack of support. This principle relates to buildings; it also applies to composing a patient’s medical record. The patient’s history provides the foundation which supports all other elements of the encounter. It frequently establishes the extent of the subsequent examination and treatment, and is important to the selection of the CPT code that determines reimbursement. Demographic and insurance information is an important part of patient registration but should not be confused with a patient history. Unfortunately, due to the complexity of evaluation and management (E/M) guidelines, the history component often exposes practices to criticism during a postpayment audit. Poorly documented histories are difficult to defend.
A medical history is a collection of data obtained from the patient. It sounds simple enough, but securing the medical history takes skill. It requires a team effort which includes technicians as well as physicians. The successful history taker is compassionate, conversational and thoughtful. Take a moment and think about what types of questions are asked. They are very personal. Certain responses may result in life-altering consequences such as surgery. From a reimbursement standpoint, the patient’s history also determines who pays for the visit: the patient or an insurance company. This monograph emphasizes the importance of documenting all of the various elements of the history and provides techniques for improved history taking.
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