The documentation in the medical record for any E/M service must include a clear statement of the complaint, which is the reason that the physician provides the service. The complaint is the first thing that should be documented for a patient visit. Yet, many times medical records fail to indicate a true complaint. Instead, the record offers as a complaint a summary of what the physician is expected to do. For example, “4 left leg” or “skin 4” or “TBSE.” While it may be necessary for the dermatologist to perform those services, those comments are not appropriate documentation of complaints.
The reason that the left leg or the skin must be checked is the complaint:
- Suppose the patient has a personal history of a skin cancer. This is the reason for a total skin check at appropriate intervals.
- If the patient has been treated for a rash on the left leg and is returning for follow up, then the complaint is “rash” or “F/U rash.”
The complaint should direct the documentation of the history of present illness (HPI), the review of systems (ROS), and the past, family, and social history (PFSH).
The complaint along with the HPI, ROS, and PFSH, generally indicates the areas to be examined. The location of the rash is part of the HPI. Documentation of the exam should relate the findings to the areas examined.
—Sharon Andrews, RN, CCS-P in Practical Dermatology, August 2010
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