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Documentation and Risk Assessment

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Presentation on theme: "Documentation and Risk Assessment"— Presentation transcript:

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

2 3 Key Components of E&M Services
History Examination Medical decision making Copyright © 2003, Elsevier Science (USA). All rights reserved.

3 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.

4 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.

5 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.

6 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.

7 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.

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

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

10 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.

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