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PODIATRIC EM CODING AUDIT SHEET Courtesy Phillip Ward, DPM HISTORY COMPONENT CC: TYPE OF HPI ________________ HPI: BRIEF = 1-3 1. LOCATION 5. TIMING EXTENDED = 4+ 2. QUALITY 6. CONTEXT 3. SEVERITY 7. MODIFYING FACTORS 4. DURATION 8. ASSOCIATED SIGNS/SYMPTOMS ROS TYPE OF ROS________________ 1. GENERAL 8. MUSCULO/SKELETAL PROBLEM PERTINENT=1 2. EYES 9. SKIN EXTENDED = 2-9 3. ENT 10. NEUROLOGICAL COMPLETE = 10+ 4. CARDIOVAS 11. PSYCHIATRIC 5. RESPIRATORY 12. ENDOCRINE 6. GI 13. HEMO/LYMPH 7. GU 14. ALLERGY/IMMUNE PFSH TYPE OF PMSH______________ 1. PATIENT’S PAST MEDICAL HISTORY PERTINENT = 1 2. FAMILY PAST MEDICAL HISTORY COMPLETE 3. PATIENT’S SOCIAL HISTORY NP = 3/3 EST PT = 2/3 DETERMINING THE TYPE OF HISTORY COMPONENT HPI BRIEF BRIEF EXTENDED EXTENDED ROS NONE PROBLEM PERTINENT EXTENDED COMPLETE PFSH NONE NONE PERTINENT COMPLETE TYPE OF HISTORY PROBLEM FOCUSED HISTORY EXPANDED PROBLEM FOCUSED HISTORY DETAILED HISTORY COMPREHENSIVE HISTORY TYPE OF HISTORY__________________________________ EXAM COMPONENT 12 ORGAN SYSTEMS 6 BODY AREAS MUSCULO/SKELETAL INTEGUMENT LEFT EXTREMITY GENITOURINARY ENT RIGHT EXTREMITY NEUROLOGIC CARDIOVASCULAR HEAD/NECK PSYCHIATRIC RESPIRATORY CHEST HEMATOLOGIC GASTROINTESTINAL ABDOMEN EYES GENITALIA BACK FOCUSED EXAM 1-5 ELEMENTS IN 1 OR MORE SYSTEMS/ AREAS EXPANDED EXAM 6-11 ELEMENTS IN 1 OR MORE SYSTEMS/AREAS DETAILED EXAM 12 OR MORE ELEMENTS IN 2 OR MORE SYSTEMS/AREAS COMPREHENSIVE EXAM AT LEAST 2 ELEMENTS IN EACH OF AT LEAST 9 SYSTEMS OR AREAS TYPE OF EXAM___________________________________ MEDICAL DECISION MAKING COMPONENT NUMBER OF DIAGNOSES/MANAGEMENT OPTIONS TYPE OF DIAGNOSIS_______________ SELF LIMITED(MINOR) = 1 POINT 1 POINT = MINIMAL ESTABLISHED STABLE/WORSENING = 2 POINTS 2 POINTS = LIMITED NEW, NO ADDITIONAL WORKUP PLANNED = 3 POINTS