Using check boxes, your patients
complete all elements of the past medical history, family
history, and social history, plus a complete review of symptoms
This results in a time savings to physicians of approximately
10 minutes per patient.
of Present Illness ( HPI )
The substance of the HPI should be obtained by the physician, though some preliminary information may be obtained and documented by the nurse. This is guided by the Intelligent Medical Records' coding prompts, which now includes the “Documentation Guidelines" requirement for a chronological description of the course of a patient's illness, as well as a listing of the eight elements of the HPI.
physician next selects the appropriate E/M code and level
based on the nature of the patient’s presenting illness(es),
including current abnormalities revealed in the ROS. IMR
coding prompts provide listings of E/M code levels for each
of CPT’s defined severities for nature of the presenting
physician can now complete the physical exam, and all components
of medical decision making. The physician follows the IMR’s
coding prompts for the amount of care and documentation
needed to fulfill the CPT requirements for the selected
In this fashion, the documentation of medical history, physical
examination, medical decision making, and medical necessity
are always compatible with the E/M code.
elements preprinted for each specialty specific exam
boxes for rapid documentation for all normal findings
lines for written documentation of abnormal findings.
optimized check boxes for data ordered and data reviwed
check boxes for treatments recommended
documentation for complexity of data reviewed
documentation of the three components of risk
documentation of nature of present problem
documentation of time ( when appropriate )
and compliant documentation for physical presence with
APRNs and / or PAs