Question

1.18 ely. D al health record documentation requirements ge otst and reflects the patients progress clinical findings, and discharge status Ci Subdomain LB.1 Analyze the the diagr documentation in the health record to ensure it supports You have been to the appropriat ashed to audit a pediaric group's medial records In addition to verifying documentation icde asiged, you are tasked with ensuring that all relevant is present in the record 1. Develop a checklist the ist of the documentation that should be incduded in a pediatric record Use the scenario below vant documentation is present in the record. s for 2. and the checklist you have developed to determine if all rele- select the appropriate code 3. Verify the E&M code assigned, If the code is incorrect, Defend your selection whether you determine it is correct or incorrect. OFFICE NOTE: 7/15/16 Timothy is a nine-month-old male who presents today with bilateral earaches. Timothy's mother states that the child has been crving and pulling at his ears for the last two days. She has also noticed a mild fever. Otoscopic examination revealed bulging tympanic membranes indicative of fluid buildup. Amoxicillin prescribed for ear infection. Script e-faxed to pharmacy CPT code assignment for visit:99202 10/09/15 Timothy had an uneventful, full-term, vaginal birth. Uncomplicated pregnancy natural childbirth. No forceps used in delivery, APGAR score at birth 8, repeat APGAR 10. HISTORY 11/10/15/ Second child, one older sister who is four years old. Parents are married. Non- smoking environment. No pets in the home. will attend daycare after mother's maternity leave ends in three months. Circumsized prior to discharge at birth. NUTRITIONAL HISTORY 11/10/15 Timothy is breastfed initially 12/13/15 Breastfeeding continues. 2/16/16 Breastfeeding continues. 4/18/16 Cereal has been introduced into diet, rice 7/15/16 Infant eats rice and oatmeal cereal, variety of fruits. No reactions noted to new foods.

Answer 1

1. The checklist of the documentation in a pediatric record are :-

- patient demographics

- consent and authorization form

- treatment history which includes :-

Cheif complaints

History of past illness

History of present illness

Physical examination

- Family history

- Financial history

- Physician orders and prescription

- Consultation

- Lab reports

- Radiology reports

- Nursing notes

- Medication list

2. The given pediatrics patient record is incomplete as it does not have the following :-

Treatment history

Lab reports

Radiology reports if any

Consent form

Consultation notes if any

3. The E&M code for the case is 99202 and it is correct. Key Component's or creteria for 99202 are :-

E/M expanded problem focused history

E/M expanded problem focused exam

E/M starightforward medical decision

Problem severity include

E/M Low and Moderate Severity Problem