Guide to Clinical Documentation 3rd Edition by Debra Sullivan

Exercise 3

Tyler Martin, a third-year medical student on a family practice clerkship, was directed to obtain a comprehensive H&P of a new patient: D. A. D. A. recently moved to your city and has never been seen at this practice. She comes in today to establish care, and she is complaining of a cough. Following is the student's documentation of the comprehensive H&P. As you read it, keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS for information that should be included in a medical record. Refer to the H&P to answer the questions that follow.

-Did any questions come to mind that you are unable to answer after reading the H&P?