Coding Corner Question: March

History Documentation Quiz

1. Who is allowed to take a patient’s history of present illness (HPI)?

1. Nurse
2. Front desk staff
3. Physician
4. Patient fills out a form and physician takes the information from it

2. Who can take the information for the review of system (ROS)?

1. Nurse
2. Physician
3. Patient fills out a form and physician takes the information from it
4. All of the above

3. How often does the past, family, and social history (PFSH) need to be documented?

1. Once a year
2. Whenever there is new information, otherwise it is permissible to refer back to the original documentation of the information
3. Never—if it is taken once, that is sufficient
4. Each time the patient sees the physician, this must be documented

4. There must be a chief complaint on every chart.

1. True
2. False

5. If a chief complaint is documented, can it simply state “follow-up”?

1. Yes
2. No

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