Internal Audit Medicine Form – Fill Out and Use This PDF

VISIT

Patient Name: __________________________________________ MRN #____________________New o Est. o

AND

Admit/Disc Date:__________________________________________ Level Billed:_____________________________

Svc Date:________________ Physician:________________________ Outpt. o Inpt. o

Observ. o Short Stay o

PATIENT

Chief Complaint:______________________________________________________________________________________

Final Diagnosis________________________________________________________________________________________

History of Present Illness (HPI)

oSymptom (What)

o Location (Where)

o Severity (Mild, Mod)

o Timing (Time of day)

o Mod. Factors (Relieved by rest)

o Quality (Sharp, dull)

o Duration

o Context (W/meals, exercise) o Assoc. Signs/Symptoms

# Elements_____

o Brief (1-3)

o Brief

(1-3)

o Extended (4-8)

o Extended (4-8)

Past, Family, Social History (PFSH)

o Past History (Illness, operations, injuries, treatments, Rx, allergies, drug reactions)

o Family History (Heritable diseases, associated risk)

o Social History (Job, habits, marital status, sexual preference, etc.)

HISTORY

# Elements__________ o None

o None

o Pertinent (1)

o Comprehensive (2 or 3 areas)

Review of Systems (ROS)

o Constitutional

o Eyes

o Ears, Nose, Mouth, Throat

o Card/Vasc.

o Respiratory

oGastrointestinal

o Genitourinary

o Musculoskeletal

o Skin/Breast

o Neurological

o Psychiatric

o Endo

o Hemo/Lymph

o Allergic/Immun. o All Others Negative

# Elements______

o None

o Pertinent (1 Syst.)

o Extended (2-9)

oComprehensive (10 >Syst)

HISTORY SUMMARY

HPI

o Brief (1-3)

o Brief (1-3) o Extended (4 > ) o Extended (4 > )

PFSH

o None

o None

o Pertinent (1)

o Complete (2 or 3)

ROS

o None

o Pertinent (1) o Extended (2-9)

o Comprehensive (10 > w/All other Neg)

If column has the same 3 elements checked, choose that column and mark below.

If no column has 3 elements checked, the column reflecting boxes checked furthest to the left will identify history.

o Problem Focused

o Expanded Problem Focused

o Detailed

o Comprehensive

Exam (Note: If normal or negative, so record. Explain w/narrative all positive or pertinent negative findings)

Body Area:

o Head, including face o Chest (Breast & Axillae)

o Abdomen

o Back, including spine

o Neck

o Genitalia, groin, buttocks

o Each Extremity

EXAM

Organ System:

o Constitutional

o Eyes

o Ears, Nose, Mouth, Throat

o Card/Vasc.

o Respiratory

oGastrointestinal

o Genitourinary

o Musculoskeletal

o Skin/Breast

o Neurological

o Psychiatric

o Hemo/Lymph /Immun.

o Problem Focused (1 body area or system) o Expanded Problem Focused (2-4 systems)

o Detailed (5-7 Systems)o Comprehensive ( 8 or more systems)

EXAM SUMMARY

o Problem Focused

o Expanded Problem Focused

o Detailed

o Comprehensive

MAKING

Table 1: Amount and Complexity of Data Obtained/Analyzed/Reviewed

o Work-Up Planned o No Work-up Planned

o Order and/or review of the report of 1> tests or pathology and lab services (80002-89399)—(1 pt)

o Order and/or review of the report of 1> tests or services in radiology (70010-79999) —(1 pt)

o Order and/or review report of 1> diagnostic studies or services in Medicine (90701-99199)—(1 pt)

o Discuss results of labs, radiology or diagnostic test with performing or interpreting physician —(1 pt)

DECISION

o Evaluating the appropriateness of and deciding to obtain old records and/or history—(1 pt)

o Review & summarize old records and/or obtain additional hx from family, caretaker, or other source to supplement that obtained from patient—(2 pt)

o Direct visualization & independent interpretation of a specimen, image, or tracing previously interpreted by another physician—(2 pt)

Total # Points_____o Minimal/Low (0-1) o Limited (2) o Moderate (3) o Extensive (4>)

Table 2: Number of DX or Management Options

Number (B) X

Points (C) = Results ( D) (Formula B X C =D)

o Self-Limited or Minor (stable, improved or worsening)

(Max 2)

1

o Established problem to examiner; stable, improved

1

o Established problem to examiner; worsening

2

o New problem to examiner; no additional workup

(Max 1)

3

o New problem to examiner; additional workup planned

4

Total

Total # Points______

o Minimal (<1)

o Limited (2)

o Multiple (3)

o Extensive (>4)

Table 3: Associated Risks: Overall measure of risk is highest level circled

Level

Presenting

Diagnostic

Medical

Problem

Procedure

Management

Minimal

o One self-limited or minor problem

o Lab Tests requiring venipuncture

o Rest, Gargles, Elastic Bandage

e.g. cold, insect bite, tinea corporis

Chest X-ray, EKG/EEG, Urinalysis

Superficial dressings

Ultrasound, eg., echocardiography

KOH prep

MAKING

Low

o 2 > self-limited or minor problems

o Physiologic tests not under stress

o Over-the-counter drugs

1 stable chronic illness

Non-cardiovascular imaging study w/contrast

Minor surgery w/no identified risks

Acute uncomplicated illness or injury

Superficial needle biopsies, clinical lab tests -

Physical or Occupational Therapy

Requiring arterial puncture, skin biopsies

IV fluids w/o additives

Moderate

o 1 > more chronic illness w/mild

o Physiologic test under stress

o Minor surgery w/ identified risks

DECISION

Exacerbation, progression, or side effects

Dx endoscopies w/no identified risks

Elective major surgery w/no

2 > more stable chronic illnesses

Deep needle or incisional biopsy

identified risks, prescription drug

Undiagnosed new problem w/uncertain

Cardiovascular imaging studies w/contrast

management, therapeutic nuclear

Prognosis, acute illness w/systemic

and no identified risk factors, obtain

medicine, IV fluids w/additives

Symptoms, Acute complicated injury

fluid from body cavity

Closed Tx fracture/dislocation

W/o manipulation

High

o 1 > more chronic illnesses with severe

o Cardiovascular imaging studies w/contrast

o Elective major surgery w/ident

Exacerbation, progression, or side effects

w/identified risk factors, Cardiac electro-

factor, emergency major surgery

Of treatment, acute or chronic illnesses or

physiological tests, diagnostic endoscopies

parenteral controlled substances

Injuries that pose a threat to life or bodily

w/identified risk factors discography

drug tx requiring intensive monitor

Function, an abrupt change neurologic

for toxicity, decision not to res-

Status.

uscitate or de-escalate care due to

Poor prognosis

Summary

o Minimal

o Low

o Moderate

o High

SUMMARY OF MEDICAL DECISION MAKING TABLES

Complexity of Data

? Minimal (<1)

? Limited (2 )

? Moderate (3)

? Extensive (>4)

Management options

? Minimal (<1)

? Limited (2)

? Multiple (3)

? Extensive (>4)

Associated Risks

? Minimal

? Low

? Moderate

? High

(Draw a line down column w/ 2-3 values otherwise drop lowest value then pick lowest remaining value)

TOTAL

? Straight Forward

? Low

? Moderate

? High

E&M DOCUMENTATION SUMMARY

History

?

Problem Focused

?

Expanded Problem Focused

?

Detailed

?

Comprehensive

?

Comprehensive

Exam

?

Problem Focused

?

Expanded Problem Focused

?

Detailed

?

Comprehensive

?

Comprehensive

Decision Making

?

Straight Forward

?

Straight Forward

?

Low Complex

?

Moderate

?

High Complexity

SUMMARY

Initial

IP Sub Care

New Outpatient and

Outpatient Established

Inpt./Observ

FU Consults

IP/OP Consults

History

D

C

C

PF

EFP

D

PF

EPF

D

C

C

PF

EPF

D

C

(Interval Hx - Sub)

or

AUDIT

C

C

Examination

D

C

C

PF

EFP

D

PF

EPF

D

C

C

PF

EPF

D

C

or

Medical Decision

SF/

M

H

SF/

M

H

SF

SF

L

M

H

SF

L

M

H

L

L

Level

1

2

3

1

2

3

1

2

3

4

5

1

2

3

4

5

Comments:

Level Billed_____________

Level Documented_____________