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Re: Patient behavior From: Anna Meenan, MD (annam@uic.edu) Tue May 22 20:46:36 2001 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: D. Ashley Hill, MD: "Re: Patient behavior" Previous message: Paul Prior MD: "Re: Patient behavior" In reply to: Garry Siegel: "Re: Patient behavior" Next in thread: Jeffrey W. Clemens: "Re: HRT combinations" Reply: Jeffrey W. Clemens: "Re: HRT combinations" I ask all the questions, but was told by our coding experts that it is acceptable to document positives and then say "all other items negative" for a comprehensive ROS. I don't think there are levels of comprehensiveness for past, family, or social history. It's documented or it's not documented, period. -- Anna Meenan, MD At Tue, 22 May 2001, Garry Siegel wrote: > >>When you dictate your note, how do you document the multiple review of >>systems and comprehensive family histories etc. required for higher >>(213/214/215) codes? Keep in mind that most of them do NOT accept >>"noncontributory" comments - you have to spell out the problems and >>that they were negative. Do you dictate all these systems each time? >> >>-- >>Paul Prior MD They that can give up essential liberty to obtain a little >>Coshocton, OH temporary safety deserve neither liberty nor safety. >>Solo Practice - Benjamin Franklin, 1759. >>OB/GYN, FACOG >> >Paul: > >FWIW, if you have a transcriptionist, or a computer voice program, you >could have a preset ROS, i.e. > >HEENT: no headahces, visual changes, etc. > >and use this as a default, making modification as needed. This would be >a "no-brainer" way to include it, by telling the transcriptionist >ROS--insert the default--and then it is there. Obviously, if the >patient has, say, a headache, you tell the transcriptionist so, and it >can be modified. > >Garry > >-- >Garry E. Siegel, M.D., F.A.C.O.G. >Roswell, GA >Private Practice > Next message: D. Ashley Hill, MD: "Re: Patient behavior" Previous message: Paul Prior MD: "Re: Patient behavior" In reply to: Garry Siegel: "Re: Patient behavior" Next in thread: Jeffrey W. Clemens: "Re: HRT combinations" Reply: Jeffrey W. Clemens: "Re: HRT combinations"

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