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alryan67

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Posts: 2
Reply with quote  #1 
My hospital's EMR notes don't have a field for this.  They have:

CC
Subjective
ROS
Data
A&P

When I list the problems and whether they are "stable, progressive, decompensated", etc, in the A&P, does this count as Interval History?

Thanks,
A

pjensen

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Posts: 773
Reply with quote  #2 

Probably not.  You should have your EMR change "subjective" to interval history.  I would NOT rely on an auditor to "tease out" your HPI by looking at your assessment and plan.

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