Comments on: Patient history http://www.kevinmd.com/blog/2008/05/patient-history.html Tue, 14 Feb 2012 11:46:00 +0000 hourly 1 By: Anonymoushttp://www.kevinmd.com/blog/2008/05/patient-history.html#comment-85456 Anonymous Wed, 07 May 2008 00:59:00 +0000 http://clients.emmense.com/kevinmd/2008/05/patient-history.html#comment-85456 One thing that integrating the CPT coding requirements into the EMR while the industry is developing is likely to do is entrench the CPT structure in place in perpetuity. <br/><br/>Makes my skin crawl. One thing that integrating the CPT coding requirements into the EMR while the industry is developing is likely to do is entrench the CPT structure in place in perpetuity.

Makes my skin crawl.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2008/05/patient-history.html#comment-85455 Anonymous Wed, 07 May 2008 00:54:00 +0000 http://clients.emmense.com/kevinmd/2008/05/patient-history.html#comment-85455 I looked at two admissions of the same patient 2 weeks apart. The initial eval, by the same doctor,evidently done by computer rather than dictation, had identical CC, HPI, dx,plan and exam--everything but the current meds. Even the vital signs and recorded verbatim statements by the patient were precisely the same--evidently a cut and paste job.<br/><br/>That would never have happened in the days of the ink pen and before the current E and M system. They guy would have just written a brief interval note for the second admission explaining why he came back and any pertinent findings. <br/> <br/>I was unable to find out why the patient was readmitted, but I do, however, know something about the professionalism and integrity of the doctor that I didn't know before. I looked at two admissions of the same patient 2 weeks apart. The initial eval, by the same doctor,evidently done by computer rather than dictation, had identical CC, HPI, dx,plan and exam–everything but the current meds. Even the vital signs and recorded verbatim statements by the patient were precisely the same–evidently a cut and paste job.

That would never have happened in the days of the ink pen and before the current E and M system. They guy would have just written a brief interval note for the second admission explaining why he came back and any pertinent findings.

I was unable to find out why the patient was readmitted, but I do, however, know something about the professionalism and integrity of the doctor that I didn’t know before.

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