Chapter Documenting a Chief Complaint: Part 2 Flashcards
1
Q
What is the first example of past medical histories that add valuable information to the chief complaint?
A
Patient with history of uncontrolled type 1 diabetes presents with numbness and tingling in both feet x1 week.
2
Q
What is the second example of past medical histories that add valuable information to the chief complaint?
A
Patient with history of migraines is complaining of frontal headaches x 24hrs.
3
Q
In order for a chief complain to be compliant with CMS documentation guidelines, avoid vague statements such as?
A
The patient feels bad or the patient feels better.
4
Q
How the MA should describe a “follow up”?
A
Follow up for diabetes then it is compliant.
