PGY-1 Curriculum: Medical Record Keeping
Problem Identification and Needs Assessment:
Targeted Learners:
PGY-1 Orthopedic Residents
Possible PGY-2 Orthopedic Residents
Needs Assessment:
Medical Record Keeping is a fundamental skill used by all physicians. Awareness of
what constitutes an acceptable medical record is important from a communications,
reimbursement and medico legal standpoint. Components of outpatient and inpatient
Encounter Charting, Discharge summaries, Operative Notes, Informed Consent and
basics of E&M coding and Billing need to be taught to residents
Educational Approach:
The learner will participate in didactic and interactive sessions to learn the basics of
good medical record keeping. The components of a record will be discussed with
regard to
E&M encounters – H&Ps, Consults, Inpatient and outpatient follow-up
Operative notes
Discharge Summaries
Coding for E&M visits
Goals and objectives:
1.
2.
3.
4.
Learn the components of an E&M note (New & Follow-up, In & outpatient).
Learn the components of an operative note.
Learn the components of a Discharge Summary.
Learn the levels of encounters for appropriate coding and billing.
Module:
Required background reading with demonstration of correct construction of above
notes. Exercises in analysis of notes with respect to completeness, levels of encounter
and billing will be done with case studies.
Learner Evaluation and Feedback:
After each note is done, it is evaluated by the faculty and immediate feedback is given.
Module will be evaluated by the learners in an anonymous way for didactic content,
usefulness of skills training and faculty evaluation.
Required Reading:
AAOS Musculoskeletal Coding Guide
Attached guidelines.
OUTPATIENTNOTEDOCUMENTATION
HPI
Components
0 Location
0 Quality
0 Severity
0 Duration
0 Timing
0 Context
0 Modifying
Factors
0 Associated
signs and
symptoms
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ROS
Constitutional
(wt. loss, etc.)
Eyes
Ears, nose,
mouth, throat
Card/vasc
Respiratory
Gl
GU
Musculo
Integumentary
(skin, breast)
Neuro
Psych
Endo
Hem/Lymph
All/Imm
All others
negative
' 95 Guidelines - Physical Exam
Organ systems AND/OR Body Areas
0 Constitutional 0 Head,
(vitals, gen app)
including face
0 Eyes
0 Neck
0 Ears, nose,
0 Chest,
mouth, throat
breasts,
0 Cardiovascular
axillae
0 Resp
0 Abdomen
0 Gl
0 Genitalia,
0 GU
groin, buttocks
0 Musculo
0 Back spine
0 Skin
0 Each
0 Neuro
extremity
0 Psych
0
Hem/lymph/imm
' 97 Guidelines - Physical Exam
See Requirements for EITHER:
-General Multi-System Examination
-Specialty Specific Examination
Number of Diagnoses
or Treatment Options
Self-limited or minor (stable,
improved, or worsening)
- 1 point each (MAX of 2)
Amount and/or Complexity
of Data to be Reviewed
Review and/or order of test from:
•Clinical lab ·1 point
•Radiology section of CPT- 1 point
•Medicine section of CPT -1 point
Est. problem (to examiner);
stable, improved
·
- 1 point each
Discussion of test results with performing
physician -1 point
Est. problem (to examiner);
worsening
·
- 2 points each
Decision to obtain old records and/or obtain
history from someone other than patient
-1 point
New problem (to examiner) no
additional workup planned
- 3 points (MAX of 3)
Review and summarization of old records
and/or discussion of case with another health
care provider -2 points
New problem (to examiner)
additional workup planned
-4points
Independent visualization of image, tracing, or
specimen itself (not simply review of report)
-2 points
MEDICAL DECISION MAKING
Risk of Complications and/or Morbidity or Mortality
*Circle the entry farthest to the bottom for each risk area.
Diagnostic Procedure(s)
Presenting Problem(s)
Management Options
Ordered
Selected
•One self-limited or minor problem {e.g. cold,
Insect bite,tinea corporis)
•Two or more self-limited or minor problems
•One stable chronic illness e.g. well controlled
HTN, non-insulin dependent diabetes, cataract,
BPH
•Acute uncomplicated illness or injury e.g.
cystitis,_ allergic rhinitis, simple sprain
•One or more chronic illnesses With mild
exacerbation, progression or side effects of
treatment
two or more stable chronic illnesses
•Undiagn o s e d new problem with uncertain
prognosis, e.g. lump In breast
·•Acute illness with systemic symptoms, e.g.
pyelonephritis, pneumonitis, colitis
Acute complicated Injury, e.g. head injury with
brief loss of consciousness
•One or more chronic illnesses with severe
exacerbation, progression or side effects of TX
•Acute or chronic Illness or injuries that m!!;y pose
a threat to life or bodily function, e.g. multiple
Trauma.. acute Ml, pulmonary embolus, severe
respiratory distress, progressive severe
rheumatoid arthritis, psychiatric illness wl
potential threat to self or others, peritonitis,
acute renal failure
•An abrupt Change in neurological status, e.g.
seizure, TIA. weakness, sensory loss
•Lab tests requiring venipuncture
•Chest x-rays
•EKGIEEG Ultrasound I Echo
•KOH prep
•Urinalysis ·
•Physiologic test not under stress e.g.
pulm function tests
•Non-Cardiovascular Imaging studies
with contrast, e.g. barium enema
•Superficial needle biopsies
eCiinicallaboratory tests requiring
arterial puncture
•Skin biopsies
•Physiologic test under stress, e.g.
cardiac stress test, fetal contraction
stress test
•Diagnostic endoscoples Wino
Identified risk factors
•Deep needle or incisional biopsy
•Cardiovascular imaging studies w i t h
contrast and no identified risk factors,
e.g. arteriogram, cardiac cath
•Obtain fluid from body cavity, e.g.
lumbar puncture, thoracentesis,
culdocentesis
•Cardiovascular imaging studies: with
contrast With Identified risk factors
•Cardiac electrophysiological tests
•Diagnostic endoscopies with
Identified risk factors
•Discography
Level
of Risk
Points for
(Circle)
Options
(Circle)
Dx!Tx
Points for
Data to be
Reviewed
(Circle)
Type of Decision
•Rest
•Gargles
•Elastic bandages
•Superficial dressings
•Over-the-counter drugs
•Minor surgery With no identified risk
factors
•Physical therapy
•Occupational therapy
•IV fluids without additives
•Minor surgery with identified risk
factors
•Elective major surgery (open
p6rcutaneous or endoscopic} with no
Identified risk factors.
•Prescription drug management'
•Therapeutic nuclear medicine
•IV fluids with additives
•Closed treatment of fracture or
dislocation without manipulation
≤1
Minimal
Minimal
≤1
Minimal
Straightforward
Low
Minimal
2
Limited
2
Limited
Low
Complex
Moderate
3
Multiple
3
Moderate
Moderate
Complex
High
≥4
Extensive
≥4
Extensive
High
Complex
•Elective major surgery {open
percutaneous or endoscopic) with
Identified risk factor
•Emergency major surgery (open,
percutaneous or endoscopic)
•Parenteral controlled substances
•Drug therapy requiring Intensive
monitoring for toxicity
•Decision not to resuscitate or deescalate care because of poor
prognosis
NEW OUTPATIENT OFFICE/CONSULTATION (3 of 3 components required)
NEW OUTPATIENTHPI:
OFFICE/CONSULTATION
(3 of 3 components
required
HPI: 1-3 Components
HPI: 4+ Components
·
1-3
History
Components
ROS: 1system
ROS: 2-9 Systems
Past, Family, Social x1
Body area/system
2-7 systems or body
2-7 systems -or body
'95 Guidelines Exam
areas With detail
areas
related to problem
1-5 elements in
6 elements in
≥6 organs, ≥2 elements
'97 Guidelines Exam
each; OR ≥ 2 organs, ≥
≥ 1 organ systems
≥1 organ systems
12 elements total
Straightforward
Low Complex
Straightforward
Decision Making
99203 (30)
99201 (10)
99202 (20)
New OP Code (Time)
.. 99243 (40)
99241 (15)
99242 (30)
Consult Code (Time)
HPI: 4+ Components
ROS: 10+Systems
Past, Family, Social x3
8 or more systems
or body areas .
≥9 organs, ≥2 elements
each
HPI: 4+ Components
ROS; 10+ Systems
Past, Family, Social x3
8 or more systems or
body areas ·
≥ 9 organs, ≥ 2 elements
each
Moderate Complex
99204 (45)
99244 (60)
High Complex
99205 (60)
. 99245 (80)
ESTABLISHED OUTPATIENT OFFICE (2 of 3 components
required)
History
'95 Guidelines Exam
Physician
presence not
required
'97 Guidelines Exam
Decision Makino
Est. OP Code (Time)
99211 (5)
HPI: 1-3 Components
HPI: 1-3 Components
ROS: 1 system
Body area or system
related to problem
1-5 elements in
≥ 1 organ systems
2-7 systems or body
areas
6 elements in
≥ 1 organ systems
Straightforward
99212 (10)
Low Complex
99213 (15)
HPI: 4+. Components
ROS: 2-9 Systems Past,
Family, Social x1
2-7 systems or body
areas with detail
body
areas With
≥
6 organs,
≥ 2 elements
detail or ≥2organs,≥
each;
12 elements total·
Moderate Complex
99214 (25)
HPI: 4+ Components
ROS: 1O+ Systems
Past, Family, Social x2
8 or more systems or
body areas
≥ 9 organs, ≥ 2 elements
each
High Complex
99215 (40)
TIME CODES need to document #1 TOTAL TIME spent face to face (Outpatient) or on the Unit/floor (Inpatient) and #2
MORE THAN HALF was counseling or coordinating care and #3 the CONTENT
that
Perform all elements identified by a bullet; document every element in each shaded box and at least one element in
each un-shaded box