Case Studies in Health Information Management
Case Studies in Health Information Management
3rd Edition
ISBN: 9781305955332
Author: Patricia Schnering, Nanette B. Sayles, Charlotte McCuen
Publisher: Cengage Learning
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When a patient is being admitted from home, the social worker should arrange for the medical records on the patient's last hospitalization. the facility should begin recording the patient's past history and background. prior medical records are generally not available. the social worker should obtain medical records from the admitting physician's office.
The purpose of obtaining a health history in today's medical office is to: a. have a basis for all treatment given by the provider and a guide for all future treatment. b. have information for the patient's personal use. c. have something to document in the patient's medical record. O d. have information for the insurance company.
When time is used as a key component in billing an E/M service, the provider must document face-to-face time with the patient and how much time was spent counseling the patient with the family.
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