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Walkthrough

PFSH and ROS

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.

History 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.

The 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 illness(es).

The 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 E/M code.

In this fashion, the documentation of medical history, physical examination, medical decision making, and medical necessity are always compatible with the E/M code.

Added Features

Physical Exam:

  • All elements preprinted for each specialty specific exam
  • Check boxes for rapid documentation for all normal findings
  • Blank lines for written documentation of abnormal findings.

 

Medical Decision Making:

  • Physician optimized check boxes for data ordered and data reviwed
  • Optimized check boxes for treatments recommended
  • Quick documentation for complexity of data reviewed
  • Quick documentation of the three components of risk
  • Quick documentation of nature of present problem
  • Quick documentation of time ( when appropriate )
  • Rapid and compliant documentation for physical presence with APRNs and / or PAs

 

 

about benefits faq walkthrough

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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 is a time savings to physicians of approximately 10 minutes per patient.

more