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Cards In This Set
| Front | Back |
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What is a Chief Complaint?
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Statement of the Medical Problem in the Patients Own Words.
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What documentation should be completed on first-time patients?
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Chief Complaint
Present History Past History Social History Family History |
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What are the 3 key components of the E/M phase of documentation?
|
History
Examination Medical Decision Making |
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CC
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Chief Complaint
|
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HPI
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History of Present Illness
|
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ROS
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Review of Symptoms
|
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PFSH
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Past Family and/or Social History
|
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What is contained on the History Elements Chart?
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Type of History
History of Present Illness Review of Systems Past Family and/or Social History |
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What must all levels of history contain?
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Chief Complaint
|
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The HPI, ROS and PFSH obtained and documented depends on clinical judgement and the nature of ....
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The presenting problems
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What are the elements for "problem focused" history?
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HPI = Brief
ROS = N/A PFSH = NA |
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What are the elements for "expanded problem focused" history?
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HPI = Brief
ROS = Pertinent PFSH = N/A |
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What are the elements for "detailed" history?
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HPI = Extended
ROS = Extended PFSH = Pertinent |
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What are the elements for "comprehensive" history?
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HPI = Extended
ROS = Complete PFSH = Complete |
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How many different guidelines are there for E/M documentation for examinations?
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2 - 1995 and 1997
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