is an inventory of body systems obtained through a series of questions that is used to identify s/s that a pt. might be experiencing.
Body/Organ Systems -
EENT, cardio, resp, GI, GU, MS, skin, neuro, psyche, endocrine, blood/lymph, allergies/immunity.
1) problem focused - cc, brief hx.
2) Expanded problem focused EPF - cc, brief HPI, problem-pertinent system review.
3) Detailed - (D) - cc, extended history, problem pertinent system review, review of additional systems, pertinent PFSH directly related to problems.
4) Comprehensive - (C) - cc, extended HPI, ROS that is directly related to the problem id'd in the hx, plus review of all additional body systems, complete PFSH.
is a health care management process done after performing a HX, and a PE, on a patient that results in a plan of TX. The HX and PE are tallied to make the MDM.
- it is based on establishing one ore more dx, selecting a management or tx option, amount or complexity of data reviewed, and risk of complications associated with morbidity and mortality.
1) number of diagnoses or management options: is based on the number and types of problems addressed during the visit. complexity of establishing a dx, number of management options that must be considered by the physician.
2) Amount or Complexity of Data to be Reviewed: based on types of Dx Tests ordered or reviewed. any extra documentation sources adds to the complexity.
3) Risk of Complications morbidity, mortality.
- based on other conditions associated with the presenting problem known as risk of complications, morbidity, mortality, comorbidities. surgery, therapy, drugs.
- determining level of risk
** to conclude the internal review of a pt's health record, a level must be determined from 4 levels:
Low complexity (LC)
Moderate complexity (MC)
High Complexity (HC)