Kim, I responded to the email sent out by PRODUCT EAR but, I will post here also.
My doctor documents Functional and Mental Status on all Medicare Wellness visits. She will also document both if not one when it applies to the patients office visit. If the patient comes in with memory or reported functional issues, she will document the status in the chart.
She documents both in the REVIEW OF SYSTEMS using a template that she has made. We use a MINI MENTAL STATE EXAM form for the Mental Status. That form, of course, is scanned into the chart along with the documentation of the results in the REVIEW OF SYSTEMS.
Thank You
Allison
Healthy Concepts Family Practice
