In order to get paid, we have to properly document our patient encounter.
Three Key Components of documentation are History, Physical Exam and Medical Decision making.
LEVELS OF EACH KEY COMPONENT:
| History | Exam | Medical Decision Making |
| Problem focused | Problem focused | Minimal Complex |
| Expanded problem focused | Expanded problem focused | Low Complex |
| Detailed | Detailed | Moderate Complex |
| Comprehensive | Comprehensive | High Complex |
There are Seven Basic Components:
1.Patient History 2. Physical Examination 3. Medical Decision Making 4. Counseling 5. Coordination of care, 6. The nature of the patient’s presenting problem (i.e., the reason for the visit) 7. Time
LEVELS OF HISTORY:
Problem Focused:
1 – 3 elements of HPI*
Status of 1 – 2 chronic medical problems**
No ROS or No PMFSH needed.
Expanded Problem Focused
1 – 3 elements of HPI*
Status of 1 – 2 chronic medical problems**
1 ROS Problem
Detailed:
4 elements of HPI*
Status of 3 chronic medical problems**
2 – 9 ROS One pertinent PFSH (PFSH NOT required for hospital progress notes)
Comprehensive:
4 elements of HPI*
Status of 3 chronic medical problems**
10 system ROS Complete PFSH (all 3)
*(1995) ** (1997)
DOCUMENTATION OF H&P:
Chief Complaint: in chronological order if more than one
History of present illness: Mention four elements of the history of the present illness
For example, if pain is the complaint, mention 4 of the following.
Location, Intensity, Quality, Associated features, Radiation, Aggravating and Alleviating factors.
If you can’t obtain history, mention the reason like in demented patients or intubated patient or altered mental status
Document if you talked to family members or friends to get more history.
Past Medical History: Do not mention ‘Non-Contributory or not on file’
Family History: Do not mention ‘Non-Contributory’
Social History: Smoking, Alcohol, Drugs
Medications:
Allergies:
Review of Systems: obtained by a questionnaire or by ancillary staff, Previous ROS obtained by YOU can be ‘recycled’ but update information and note the date and location of the ROS
A review of at least 10 systems should be mentioned. You don’t have to say all these written below. Just mention positive findings and say “All other systems are reviewed and are negative.”
Constitutional: fever, chills, night sweats, weight change, fatigue, malaise, nutrition, grooming
Eyes: vision, pain, discharge, photophobia
Ears/Nose/Throat: hearing, tinnitus, dizziness, pain, discharge, smell, hoarseness, nose bleeds, lesions
Cardiovascular: Palpitation, chest pain, shortness of breath, PND, orthopnea, syncope, varicosities, edema
Respiratory: asthma, dyspnea, cough/sputum, hemoptysis, TB skin test status
Gastrointestinal: dysphagia, anorexia, nausea, vomiting, hematemesis, diarrhea, constipation, melena, rectal bleeding, change in bowel habits, hemorrhoids, jaundice, abdominal pain
Genitourinary: dysuria, hematuria, frequency, polyuria, urgency, hesitancy, incontinence, renal stones, nocturia
Male Reproductive: penile discharge, STD history, testicular pain or mass
Female Reproductive: postmenopausal symptoms, abnormal bleeding, STD history
Musculoskeletal: joint pain, edema, redness, stiffness, deformity, muscle pain, tenderness, atrophy
Neurological: headache, syncope, vertigo, seizures, loss of vision, diplopia, paresthesia, weakness in any limbs, tremor, ataxia, memory loss
Skin: itching, rash, lump and bumps, hair and/or nail change, de/pigmentation
Endocrine: excessive thirst, sweating, dizziness
Hematologic/Lymphatic: bruising, cyanosis, lymphadenopathy, petechiae, purpura
Psychiatric: stress, insomnia, previous psychiatric illness, hallucinations
If any part of history cannot be obtained there must be a notation as to why (such as the patient’s condition – “Ex: unable to obtain as patient intubated”)
Physical Exam: SEVEN BODY AREAS/ TWELVE ORGAN SYSTEMS
Vitals:
Constitutional:
HEENT: Normocephalic, Icterus, pallor, mucosa, lymphadenopathy, pupils, extra ocular movements, oral exam
Chest: Heart sounds, murmurs,
Lungs: Breath sounds, accessory muscles, tenderness
Abdomen: scars, bowel sounds, tenderness, organomegaly, distension, ascites, masses, rectal exam
Genitourinary:
Extremities: edema, varicose veins, ulcers, pulses, scars, tenderness, clubbing, petechiae, gangrene
Neurologic: orientation, Level of consciousness, memory, speech, cranial nerves, deep tendon reflexes, strength, tone, & cerebral function, Sensation, Cerebellar signs, Gait, movements
Musculoskeletal: Inspection/palpation, Range of Motion, Stability, Muscle Strength & Tone
Skin: rash, Induration, swelling, ulceration
Psychiatric: affect, depression, anxiety, agitation
For Physical Exam: stating NORMAL/NEGATIVE in a system is OK but if there is an Abnormal finding, it MUST BE DESCRIBED
Labs:
Mention that you reviewed EKG and it shows….
Same with imaging, reviewed chest x ray and it showed…. (if you actually did.)
Be an “I” specialist – Take credit for what you did. “I personally reviewed the following lab work and per my interpretation– “I’ve discussed the findings with Radiologist” OR Cardiologist, etc. — “I requested for outside Medical records — “I reviewed the old records and it shows in summary
Assessment and Plan
Medical Decision Making: Most important key component- reflects the actual cognitive labor required for a given patient encounter. E&M guidelines use three dimensions to quantify medical decision making 1) Nature and number of problems or diagnosis 2) Extent of data reviewed 3) Risk to the patient
Explain the plan for each diagnosis.
Mention IV medications including IV fluids, antibiotics, pain medications, etc.
Mention about DVT prophylaxis.
List EVERY problem addressed (even if you just review the medications) as it helps portray the complexity, mortality, morbidity and risks of medical decisions – Remember CCs and MCCs for DRGs built (E/O ratio ~ 1)
If not sure about exact diagnosis, can state PROBABLE/Suspected, RULE OUT, etc. but should later clarify if listed diagnoses are no longer suspected or confirmed – Also remember 5Ss of success (Side, Status, Specific site, suggest secondary to, Scores and scales makes you smart)
If it is not POA [Present on Admission] – It is HAC [Hospital Acquired Condition]
Expected mortality should be equal to Observed mortality – it is in your hands (documentation). Observed mortality – actual inpatient deaths. Expected mortality – those inpatients who are expected to die during the hospitalization based on the clinical documentation in the medical record.
Remember 5S – Side, Status, Specific Site, suggest secondary to, Look Smart (scales and scores for Risk
Goal is to write shortest note possible (Quality over the quantity).
Risk is quantitative, use the E/M tables to get familiar with it.
Don’t add problems or data points to beef up MDM, Risk is the Key.
History and Exam are comprehensive at admission.
Principal Diagnosis: That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Must be present on admission (POA).
