This Rapid Tutorial lays out documentation samples specific to the history component of the initial visit documentation. Continue your training by seeing what an initial office visit history looks like in the context of your documentation. Remember, for this module, and the remaining modules in this course, refer to the first module that contains the…
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The Three Areas of Past, Family and Social History (PFSH) When a patient presents for evaluation of their health concern, we have a responsibility to thoroughly collect their Past, Family, and Social History (PFSH). This Fact Sheet explores the three areas of the PFSH and how they relate to ordering examinations, radiology, additional testing, and/or…
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Review of Systems Affecting Patient Care “Look well to the spine for the cause of disease” is a commonly used quote from Hippocrates regarding chiropractic. Because chiropractors are so focused on the spine as the source of a patient’s complaint, it is common to overlook the other body systems during an examination. Or more likely,…
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History of Present Illness (HPI) and OPQRST One of the most important elements of a patient evaluation is collecting his/her History of Present Illness (HPI). The HPI elements that a patient normally presents with have a direct clinical correlation to the type and severity of the condition for which they are being treated. These elements…
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Download Support Tool The Intake System of your practice is vitally important to maintaining an accurate chart for each of your patients. This collection of information is the precursor to building a medically appropriate history through proper E/M services. This tool gives providers an easy-to-use checklist to compare the office intake forms with what is…
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Intake History Process Despite its importance, the intake history process is often overlooked. To provide the patient with the best experience possible, start the process before the patient even steps foot in the office. Once a patient sets up an appointment, begin to collect history and demographic information. This process should be as smooth and…
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