History: Going the Distance. Suzan Berman, CPC, CEMC, CEDC
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1 History: Going the Distance Suzan Berman, CPC, CEMC, CEDC
2 Publisher Notice Although we have tried to include accurate and comprehensive information in this presentation, please remember it is not intended as legal or other professional advice. 2
3 Objectives What makes up the history component? Who can document it? How should it be illustrated? When should it be updated? Why is it so important? 3
4 The History Components History of present illness Past history Social history Family history Review of systems 4
5 Where Can We Get the History? Patient: Complete a form Interview Family: Interview Other practitioners/providers: Chart notes Conversations Past medical record Chart records 5
6 Patient Information Sheet This form can be known as the: Patient information sheet Health history form Intake form New patient form Initial assessment form Health history questionnaire Information questionnaire 6
7 Patient Information Sheet continued This form should be created with input from all the different areas of the practice: Coders can add required coding information (specific systems, information about the current issue, etc.). Physician what is needed to evaluate the patient appropriately? Front desk what insurance information, contact information, etc., would be needed? 7
8 Patient Name: Birthdate: Date: Requesting Physician: Address: Pharmacy Name: Phone number: ( ) Reason for today s visit: Please describe this problem: Please list all operations, type of anesthesia used and the appropriate date: (1) General anesthesia (asleep) (2) Spinal (numb from waist down) (3) Local (just one area numb) SURGERY TYPE ANESTHESIA TYPE YEAR PRIOR ILLNESSES DATE DIAGNOSED DESCRIPTION Please list all medications (prescriptions and non-prescription) that you take. (Include herbal remedies, vitamins, over-the-counter, street drugs, prescriptions, etc.) NAME OF MEDICATION DOSAGE TIME OF LAST DOSE Do you take any blood thinning products such as Plavix, Coumadin, Aspirin? No Yes Do you have any food, environmental, or drug allergies? No ALLERGY TYPE REACTION Yes (please explain below) Past or ROS
9 Social History Family History Do you smoke? No, and never have Yes (please explain below) TYPE OF SMOKING(cigarette, pipe, marijuana, chew, etc) HOW MUCH HOW LONG Do you drink alcohol? No, and never have Socially only Daily Beer/Wine Hard Liquor Please describe any family health issues below. FAMILY HISTORY Good/None Unknown Illnesses/Reason for Death Mother Father Sibling(s) Other hereditary illness Patient Signature: Date: Physician Signature: Date reviewed: Important to illustrate the MD review.
10 PE R SONAL HISTORY FORM Do you have or have you had any of the follow ing medical conditions? (Circle the correct answer) No Yes Don t know No Yes Don t know General Kidneys and Bladder Difficulty sleeping N Y? Kidney disease N Y? Change in weight N Y? Kidney stones N Y? Cancer N Y? Renal failure N Y? Dialysis N Y? Skin Bladder problems N Y? Poor healing N Y? Bloody urine N Y? Leg wounds N Y? Urinary infections N Y? Easy bruising N Y? Gynecologic Are you pregnant N Y? Menstrual problems N Y? Eyes Blurred vision N Y? Ears, Nose, Throat Neurologic Decreased hearing N Y? Numbness N Y? Stroke N Y? Endocrine Mini - stroke N Y? Diabetes N Y? Headaches N Y? Thyroid problems N Y? Seizures N Y? Light - headed N Y? Notice the need for an answer on each line
11 Lungs Short of breath N Y? Musculo-skeletal Cough N Y? Back pain N Y? Asthma N Y? All recognized Arthritis N Y? Emphysema N Y systems? should Leg cramps N Y? Blood clots in lung N Y? be illustrated Vascular Heart on the form. Blood clots in legs N Y? Chest pain N Y? Circulation problem N Y? High cholesterol N Y? Varicose veins N Y? High blood pressure N Y? Hardening arteries N Y? Irregular heart beat N Y? Phlebitis N Y? Pacemaker N Y? Pain with walking N Y? Heart attack N Y? Congestive heart failure N Y? Psychologic Stress N Y? Gastro-intestinal Anxiety N Y? Abdominal pain N Y? Depression N Y? Stomach ulcer N Y? Gallstones N Y? Coagulation Hepatitis N Y? Clotting problems N Y? Nutrition problems N Y? Bleeding problems N Y? Other problems: Reviewed by: Signature: Date: Important to illustrate the MD review.
12 Chief Complaint Can be in the patient s own words Should be symptoms or actual physical conditions, not the mechanism of injury Will probably not be a defined diagnosis Must be documented by the physician 12
13 How do these work? I just don t feel right Car accident Patient is here for follow-up Mrs. Caesar says her wound is still open Patient is here to establish No complaints Patient presents for follow-up after hernia surgery 13
14 Better Chief Complaints Patient is complaining of low-grade fever for three days My stomach hurts Patient is here for follow-up of her new diagnosis of IDDM Sore throat 14
15 HPI Elements Location Duration Timing Quality Severity Modifying factor Context Signs/symptoms 15
16 Sample HPI She is a 68-year-old lady who is being followed by you for a left upper lobe mass (location) (chief complaint is now established) as well as a 2 cm lymph node (severity?) in her AP window. During her evaluation,(context) there was some question regarding a history of aortic stenosis. The HPI above can help to satisfy only code levels up to a or a for new/consultation. 16
17 Another HPI Sample I am seeing Greg Storm for a three-day history of stabbing stomach pain that is not relieved with Tums. He first noticed this when finishing dinner at The Mexican Hat Restaurant. 17
18 Let s Discuss The patient s wound is open, oozing, odorous, and red. It s been like this for two days. She denies pain in this area. Location? Quality? Severity? Duration or timing? Signs/symptoms? 18
19 Another HPI Scenario Patient is feeling well today. Mr. Dodson has CAD, hyperlipidemia, S/P CABG. His lab work showed cholesterol of 250. He had an ultrasound performed that showed no changes from Sept He is able to walk a block without stopping vs. 1997? Location? Duration? Severity? Modifying factor? Context? Signs/symptoms 19
20 Past History Allergies Current medications Immunizations Previous trauma Surgeries Previous illness Previous hospitalizations 20
21 Could this be a past medical history? Patient denies any prior illnesses. Previous illnesses? Patient is a vegetarian. Patient is on OTC vitamins. Mr. Frank is on no medications. Dietary status? Medications? Medications? 21
22 Social History Drug use Alcohol consumption Tobacco use Employment Sexual history Marital status Education Occupational history 22
23 Can a patient deny social history? Patient has 2 dogs and 1 cat. Living arrangements? G10 P8 A2 Sexual history? Patient is a retired coal miner. Occupational history? Employment? 23
24 Family History Health of parents or cause and age of death Health of siblings and children Family members with disease related to the chief complaint 24
25 Who s family? Noncontributory What does this mean? Unremarkable What does this mean? Patient is adopted Immediate family? Patient has dementia and doesn t recall having a mother Parents? 25
26 Example of History Documentation The patient s past medical history is notable for hyperlipidemia (past history-illness) and a bicuspid aortic valve. He does have known coronary artery disease and previously underwent a PTCA of the circumflex artery in He has no prior surgical history (past history surgery), and HAS NO KNOWN DRUG ALLERGIES (past history allergies or ROS allergy/immunology). His medications include Lopressor (past history meds). The patient is a former 20- pack-year smoker (social history tobacco use) and does not drink regularly (social history alcohol use). Family history is noncontributory (noncontributory is not advised a better statement could have been that the patient s family history is negative for any cardiac issues). With a better family history, this documentation could support a higher level of service. (99204, 99205, 99244, 99245) 26
27 Review of Systems Constitutional Eyes Ears, nose, mouth/throat Cardiovascular Respiratory Gastrointestinal Genitourinary Allergic/immunologic Integumentary Neurological Endocrine Psychiatric Hematologic/lymphatic Musculoskeletal All others reviewed and negative 27
28 That s a lot of information? Review of systems is noncontributory. ROS was unobtainable. All systems are negative. See as above in HPI, ROS unremarkable. How can that be? Why? What brought the patient to the office? What does this mean? 28
29 What if the history components are unobtainable? To get the proper credit for the history retrieval, you must document the following: Any attempts you made to get the history: I spoke with the resident/nurse/family to gather the patient s medications. Why weren t these details obtainable? The patient s condition was of an urgent nature. Gathering the social history was not warranted at this time. Gathering the patient s family history was not pertinent to the patient s emergent condition. Patient suffers from dementia and is a poor historian. 29
30 Thank You. Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services Health Revenue Assurance Associates, Inc
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Phone (573) 256-7700 * Fax (573) 256-3003 PATIENT HISTORY FORM Name Date of Birth M/F Date and Time of Appointment Referring Physician Preferred Pharmacy Reason for Appointment Height PHYSICIANS (Please
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
We are looking forward to meeting with you and assisting in your cardiac care. Thank you, Metropolitan Heart and Vascular Institute.
Thank you for scheduling an appointment at Metropolitan Heart and Vascular Institute. We are looking forward to meeting you. Enclosed are our patient registration forms. Please complete these forms to
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE
NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE Name: DOB: Please give us as much information as you can about your prior medical history. If possible, give dates, medication doses, names and phone numbers
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Dr. Hall New Patient Paperwork Please fill out these forms completely
Dr. Hall New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
Medical Questionnaire
Medical Questionnaire Date: Day Month Year Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician