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  • Interval Instructions

    Transféré par

    esbat07
    159 vues2 pages
    The document describes an interval health history and physical examination form that can be used for subsequent patient visits that do not require a full health and physical exam. The form collects a patient's medical history, family and social history, health risk assessment, and physical exam findings. It is available in adult and pediatric versions. The form is designed to provide thorough patient information to meet program requirements and support clinical decision making and reimbursement. It includes sections for immunizations, lead assessment, preventive health education, exam findings, testing, medications, follow-up recommendations, and referrals.

    Description originale:

    Physical examination instructions

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    The document describes an interval health history and physical examination form that can be used for subsequent patient visits that do not require a full health and physical exam. The form collects a patient's medical history, family and social history, health risk assessment, and physical exam findings. It is available in adult and pediatric versions. The form is designed to provide thorough patient information to meet program requirements and support clinical decision making and reimbursement. It includes sections for immunizations, lead assessment, preventive health education, exam findings, testing, medications, follow-up recommendations, and referrals.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    159 vues2 pages

    Interval Instructions

    Transféré par

    esbat07
    The document describes an interval health history and physical examination form that can be used for subsequent patient visits that do not require a full health and physical exam. The form collects a patient's medical history, family and social history, health risk assessment, and physical exam findings. It is available in adult and pediatric versions. The form is designed to provide thorough patient information to meet program requirements and support clinical decision making and reimbursement. It includes sections for immunizations, lead assessment, preventive health education, exam findings, testing, medications, follow-up recommendations, and referrals.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 2

    INTERVAL HEALTH HISTORY AND PHYSICAL

    EXAMINATION FORM
    (H&P-14 Adult, H&P-14 Peds)
    Purpose
    Toprovideathoroughanduptodatepatientmedicalhistory,familyandsocialhistory,
    healthriskassessmentandphysicalexaminationtomeetprogramandprovider
    requirements,aswellastheneedsoftheclient.
    Initiation and Maintenance
    IntervalHealthHistoryandPhysicalExaminationForm(H&P14,Adultor
    Pediatricversion)istobeusedasanintervalhistoryandphysicalexaminationformfor
    subsequentvisitsthatdonotwarrantanentireupdatedH&P13.
    NOTE:Thereare2versionsoftheIntervalHealthHistoryandPhysicalExamination
    form:
    1. Adult(age21andolderorallFamilyPlanningpatients)
    2. Pediatric(age20and under)
    Instructions for Completion
    UseCorDlabelwiththepatientsname,patientIDnumberandHID/LOCSite.Ifa
    labelisnotaccessible,enterthepatientsname,IDnumber,andtheHID/LOC/SITEof
    site.
    Thetopsectionofpage1isdesignedtobefilledoutbythepatientwithreviewbya
    healthcareprovideratthetimeofthevisit.Patient/Parentsignature,healthcareprovider
    signature,anddatearerequired.
    ImmunizationStatus,LeadAssessment,andPreventiveHealthEducationarecheckboxes
    intheshadedportionofpage1andareforspecificinformationdiscussedwiththepatient
    atthetimeofthevisit.Thisisdesignedtoaidtheproviderinmeetingprogram
    protocols/guidelinesandstandardsforreimbursement
    TheExamsectionsonpage2oftheformaretobecompletedasappropriatetomeetthe
    treatmentandcounselingneedsofthepatient.
    TheExamsectionscontainscheckboxesfor
    o GeneralMultiSystemExam
    o AssessmentandPlan
    o Testingperformed
    o Medications,
    o RecommendationstoclientforFollowuptesting,
    o Referralsmadetothepatientatthetimeofthevisit.
    Thesesectionsaredesignedtoaidtheproviderinmeetingprogramprotocols/guidelines
    andstandardsforreimbursement.
    InformationdocumentedinthisformdoesnothavetoberepeatedontheCH3aProgress
    Notes.

    AseparateHRAisnotneededwiththecompletionofthisformsincethequestionsare
    includedinthehistorysections.

    ImportantAllblanksspacesandsectionsaretobefilledintomeetPHPRprogram
    guidelines/protocols,codingandbillingrequirements,cliniciandiscretion,orpatient
    preferences.Thehealthcareproviderswilluseprofessionaljudgmentandprogram
    requirementstodeterminewhatmedicalinformationtogatherfromtheclient.Sectionsmay
    beXdoutifnotappropriatetotheserviceordesignatedasdeferredifomittedbecause
    ofpatientpreference.N/Amaybeusedtodesignateifthehistoryorphysicalitemisnot
    applicable.Thesymbolmaybeusedwhenthepatientreportsnoneatthistimeduring
    thevisit.Leavingblankspacesexposesthehealthcareprovidertoquestionsthatinformation
    mayhavebeenfilledininformationortamperedwith.SeePHPR,
    Documentation/MedicalRecordsSection.

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