Understanding the Different Codes Contributing, Research Paper Example

Understanding the Different Codes Contributing to Good Patient Management and Evaluation

Introducing the Components of UB-04

There are three particular components of patient management and evaluation process that medical institutions take into account. These components include a problem focused examination, expanded problem focused examination, detailed examination and comprehensive examination (1997 Documentation, 12) that have been done in the past in coordination with the current situation of the patient regarding his or her health concerns. Most often than not, physicians are given ten minute actual examination and face-to-face consideration with the patient in connection with their health complaints. Nonetheless, this does not mean that everything is addressed within the said span of time. Instead, the physicians would have to record certain findings and require examinations that are needed to confirm particular diagnosis of the situation that a patient is dealing with. This source of information is often known as the PFSH data or the Past, Family and/or Social history data (1997 Documentation, 9). From this set of information, these examinations and their results ought to be recorded.. Remarks from the physicians during the check-up visit such as particular medication prescriptions and other matters that include the elemental factors that are needed to be considered especially when it comes to making a deep definition of the medical condition of a patient are also to be keenly recorded. This recorded information is expected to make an implicative indication on what medical procedures shall be considered to impose healthful definitions towards the recovery of the patient/s being served. The data to be kept are supposed to be defined as the historical background of the patients being attended to; hence shall be used as reference for the current health conditions of the patient and the needed approaches that are supposed to be given attention to so as to aid the patient/s’ recovery.

The problem focused examination is understood to be considered as an option of development especially referenced on the past operations and medical developments that have been imposed on the patient/s from the past years of medical appointments with other physicians. The problem focused examination is a recorded note on the different indications that are relatively connected with the developments that are needed to understand the current medical condition of the patient. The straightforward decision making recorded as part of the patient/s’ history is a noted final diagnosis of the last physician who has attended to the patient/s who is/are currently being attended to for medical assistance and diagnosis. To make the current diagnosis more effective and definitive of the relative condition of the patient being attended to, a record on the counseling or coordinating care of other agencies who have also given assistance to the patient in the past could also help in determining the assumption of the patients’ healthcare status. This indicates a relative consideration over the moderate to high severity of the health concern of the patient/s.

The collected information is defined to provide a more intricate understanding on how the health situation of a patient has come into development to the case situation that is happening to the patient at present. Notably, through the use of this information, the diagnosis of the health case that a patient experiences at present could be further reformed in accordance with the development that is tracked down from the history or the background of the patient towards the current status of the individuals’ health. Relatively, this collected information are expected to make a definitive indication on what particular procedures and medication that are needed to be given attention to so as to assure the patients’ recovery.

References

1995 Documentation Guidelines for Evaluation and Management Services.

1997 Documentation Guidelines for Evaluation and Management Services.

Evaluation and Management. http://www.astro.org/HealthPolicy/RadiationOncologyCoding/CodingFAQ/EvaluationAndManagement/index.aspx. (November 21, 2011).