Chapter Documenting a Chief Complaint: Part 2 Flashcards

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1
Q

What is the first example of past medical histories that add valuable information to the chief complaint?

A

Patient with history of uncontrolled type 1 diabetes presents with numbness and tingling in both feet x1 week.

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2
Q

What is the second example of past medical histories that add valuable information to the chief complaint?

A

Patient with history of migraines is complaining of frontal headaches x 24hrs.

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3
Q

In order for a chief complain to be compliant with CMS documentation guidelines, avoid vague statements such as?

A

The patient feels bad or the patient feels better.

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4
Q

How the MA should describe a “follow up”?

A

Follow up for diabetes then it is compliant.

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