tci Part B Insider - 2003 Issue 34

History: Those Who Take a Lousy History Are Condemned to Repent It

4 tips on obtaining a great patient historyIt only takes a few minutes for your physician to obtain all the details of where the patient's illness came from and what the patient is experiencing. And it should only take you a few minutes to turn this into useful documentation. But if those two things fall into chaos, it can mean hours of aggravation. Luckily, coding experts offer some tips on obtaining the perfect patient history:  Remember the difference between the history and the exam. Especially when it comes to the review of systems (ROS) portion of the...

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