1. There are four components to an evaluation and management visit. Which one should drive the visit?
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Explore This IssueApril 2012
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- Chief complaint
- Medical decision making
2. The term “follow-up visit” can be listed as the chief complaint in a patient’s medical record.
3. The history of present illness documentation in a patient’s chart indicates two stable chronic diseases. What does that equate to for the number of diagnosis or treatment options under the medical decision making?
4. What is a cloned note?
- A photo copy of a note
- The electronic version of the note
- A bad movie
- The cutting and pasting of information entered in an electronic health record (EHR) from a past visit
5. A practice is safe from being audited for cloned notes because the EHR chooses the code.