Emergency department Facility level calculation
For billing of medical records and to code a particular chart patients are identified as two types one is new and other is established patient, depending on encounters with the provider. But in Emergency department a patient will be always a new patient.
New Patient: A person who has not received any professional services from the physician or another physician of the same speciality who belongs to the same group or department within the previous 3 years.
Established Patient: A person who received professional services from the physician or another physician of the same speciality who belongs to the same group or department within the previous 3 years
Chief Complaint (CC): A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.
History of present illness:
|History of the present illness||Review of systems|
|Elements||Constitutional Symptoms||for example, fever, weight loss|
|Quality||Aching, burning, radiating pain||Ears, nose, mouth, throat||Normal|
|Severity||10 on a scale of 1 to 10||Cardiovascular||Normal|
|Duration||started 3 days ago||Respiratory|
|Timing||constant or comes and goes||Gastrointestinal|
|Context||lifted large object at work||Genitourinary|
|Modifying Factors||Better when heat is applied||Musculoskeletal|
|Assoc signs and symptoms||Numbness in toes||Integumentary (skin and/or breast)||Laceration to hand|
· Extended=4+or status of 3 or more chronic conditions
|Past medical history||Family history||Social History|
|Past illness||Family illness||Smoking|
|Past surgeries||Hereditary disease||Alcohol drug use|
|Allergies||Health status of family members||Living arrangements|
|Current meds||Employment occupation|
|Past hospitalization||Marital status|
Established patient, Emergency department Visit
· Pertinent PFSH= 1 element from any history
· Complete PFSH=1 element from any 2 history areas
New patient , initial encounter
· Pertinent PFSH= 1 Element from 1 or 2 history areas
· Complete PFSH=1 element from each of the 3 history
HPI Calculation Table:
Count the examination as either a body area or organ system but do not club it based on 1995 and 1997 guidelines.
|1.Body area||2. Organ system|
|Chest||Ears, nose, mouth, throat|
|Integumentary (skin and/or breast)|
Physical Examination Calculation Table:
Medical decision making:
Based on the level of Risk medical decision making is calculated. Below is the table for reference.
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