Question: Audit Report 1.5 Progress Note LOCATION: Inpatient. Hospital PATIENT: David R Harris Attending PHYSICIAN: Timothy L Pleasant, MD Subjective: The Patient Is Doing Very Well Today. His Lower Back Pain Much Better After He Has Had The Epidural Pump. He Complains Of Increased Secretions In The Trachea And Some Rattling Noise And Pain His Chest When He Breathes. …

AUDIT FORM HISTORY ELEMENTS Documented HISOTORY OF PRESENT ILLNESS(HPI) Location (site on body) Quality (characteristic: throbbing, sharp) Severity (1/10 or how intense) Duration * (how long for problem or episode) Timing (when it occurs) Context (under what circumstances does it occur) Modifying factors (what makes it better or worse) Associated signs and symptoms (what else is happening when it occurs) *Duration not in CPT as an HPI Element TOTAL LEVEL REVIEW OF SYSTEMS (ROS) Documented Constitutional (e.g., weight loss, fever) Ophthalmologic (eyes) Otolaryngologic Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breasts) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic TOTAL LEVEL PAST, FAMILY, AND IOR SOCIAL HISTORY (PESH) Documented Past illness, operations, injuries, treatments, and current medications Family medical history for heredity and risk Social activities, both past and present TOTAL LEVEL History Level 1 2 3 4 Detailed Problem Focused Comprehensiv Expanded Problem Focused e HPI Brief 1-3 Brief 1-3 Extended 4+ Extended 4+ ROS None Problem pertinent 1 Extended 2-9 Complete 10+ PESH None None Pertinent 1 Complete 2-3 HISTORY LEVEL MDM ELEMENTS Documented # OF DIAGNOSIS/MANAGEMENT OPTIONS Minimal Limited Multiple Extensive LEVEL AMOUNT ANDIOR COMPLEXITY OF DATA TO REVIEW Documented Minimal/None Limited Moderate Extensive LEVEL RISK OF COMPICATION OR DEATH IF NOT TREATED Documented Minimal Low Moderate High LEVEL MDM* 1 2 3 4 Straightfor Low Moderate High Minimal Limited Multiple Extensiv Number of DX or management options Minimal/No Limited Moderate Extensive Amount and/or complexity of data ne Risks Minimal Low Moderate High MDM LEVEL *To qualify for a given type of MDM complexity, 2 Of 3 elements in the table must be met or exceeded EXAMINATION OF ELEMENTS Documented CONSTITUTIONAL (OS) Blood pressure, sitting Blood pressure, lying Pulse Respirations Temperature Height Weight General Appearance (Count as only 1) NUMBER BODY AREAS (BA) Documented Head (including face) Neck Chest (including breasts and axillae Abdomen Genitalia, groin, buttocks Back (including spine) Each extremity IUMBER ORGAN SYSTEMTS (OS) Documented Ophthalmologic (eyes) Otolaryngologic (ears, nose, mouth, throat) Cardiovascular Respiratory NUMBER TOTAL BAIOS Exam Level 1 2 3 4 Problem Focused Expanded Problem Focused Detailed Comprehensi ve Limited to affected BAJOS Limited to affected BAIOS & other related OS(s) Extended of affected & other related OS(s) General multi-system (Oss only) 1 # of OS or BA 2-7 limited 2-7 extended 8+ EXAMINATION LEVEL History: Examination: MDM: Number of Key Components: Code: 5