Reviewing of Medical record and decision Making Q & A

Q. Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?
A. Yes – review of “old records” is part of the medical decision-making process.

Q. If I review my own previous notes and summarize my findings, would I get credit for “review and summation of old records”?
A. No, credit would not be given for summarizing one’s own previous records.

Q. If I document allergies, do I get credit for an element of past medical history, or is this counted as part of the review of systems (Allergic/Immunologic) (or both)?
A. The single element of allergies would only be counted once (for either past medical history or review of systems).

Q. Can I use elements of History of Present Illness (HPI) as elements of Review of Systems (ROS) and have them both count, or is it one or the other? For example if the patient has chest pain which is “associated with shortness of breath” in the HPI, does this also count as an element of respiratory ROS?
A. The same element would only be counted once. In the example given, there are two different elements indicated (shortness of breath and chest pain), so this would count for both HPI and ROS, respectively.

Q. Do you use the numeric conversion for the 1995 E/M guidelines (i.e., problem focused exam: one system and/or body area, expanded problem focused exam: 2-4 organ systems and/or body areas, detailed exam: 5-7 body areas and/or organ systems, comprehensive: 8 organ systems)?
A. The 1995 guidelines do not specify exact numbers — problem focused implies one system/area, and only comprehensive has a numeric indication (8).

Q. What is the definition of “self-limited” or “minor” problem vs. “new stable problem?”
A. A new, stable problem is a new problem, which is not worsening. A self-limited or minor problem is of less severity and would be expected to run its course uneventfully.

Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”
A. Yes — when referring to previous notes, specific information must be given regarding when and where.

Q. When calculating the medical decision-making, are problems defined as “old” or “new” relative to the patient or to the physician?
A. Regarding the medical decision-making component, the designations of “old” and “new” are relative to the physician.

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