Documentation and Risk Assessment

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Presentation transcript:

Documentation and Risk Assessment Chapter 7 Documentation and Risk Assessment Copyright © 2003, Elsevier Science (USA). All rights reserved.

3 Key Components of E&M Services History Examination Medical decision making Copyright © 2003, Elsevier Science (USA). All rights reserved.

Copyright © 2003, Elsevier Science (USA). All rights reserved. E&M Services All 3 key components must be present in the following categories of E&M services: All consults except follow-up consults Initial hospital care Comprehensive nursing facility Emergency room services New patients, office Copyright © 2003, Elsevier Science (USA). All rights reserved.

Copyright © 2003, Elsevier Science (USA). All rights reserved. E&M Services Only 2 out of 3 key components must be present in the following categories of E&M services: Follow-up consults Subsequent hospital care Subsequent nursing facility Established office patients Copyright © 2003, Elsevier Science (USA). All rights reserved.

Copyright © 2003, Elsevier Science (USA). All rights reserved. Types of History Problem focused Expanded problem focused Detailed Comprehensive Copyright © 2003, Elsevier Science (USA). All rights reserved.

Copyright © 2003, Elsevier Science (USA). All rights reserved. Elements of History Chief complaint History of present illness Review of systems Past, family, and social history Copyright © 2003, Elsevier Science (USA). All rights reserved.

Copyright © 2003, Elsevier Science (USA). All rights reserved. Types of Examination Problem focused Expanded problem focused Detailed Comprehensive Copyright © 2003, Elsevier Science (USA). All rights reserved.

Types of Medical Decision Making Straightforward Low Moderate High Copyright © 2003, Elsevier Science (USA). All rights reserved.

Figure 7-3 The four Cs of an operative report Copyright © 2003, Elsevier Science (USA). All rights reserved.

Table 7-1 Medical decision making matrix Type of Medical Decision-Making Number of Decisions/ Management Options Amount and/or Complexity of Data Risk of Complications and/or Morbidity or Mortality Straightforward Minimal Minimal/None Low complexity Limited Limited/Low Low Moderate complexity Multiple Moderate High complexity Extensive High Copyright © 2003, Elsevier Science (USA). All rights reserved.