Home Forums Discussions General Discussion New vs Established patient

I wonder if any body know how to documment on the patient encouter that the patient is new or established.
I just found out that is a must issue to be present some where on the encouter form, either in a check box or some where else. It is required for coding and payment by third party if your chart is audited.
Any input is appreciated.

Wouldn't the fact that there are no prior entries on the patient speak for itself? The record is just being opened/data just being entered. It is mind boggling the lack of common sense in what we are being asked to do. What a waste of time. No prior records....obviously a new patient. Give me a break! Who is asking you to this. Let them come and audit. Wachos! Sorry. It is just so ridiculous. I have to start documenting the lanquage my patients speak even though there is no patient in my practice who speaks anything but english. I am rural canadian border. Don't even have any french canadians.

I just note in cc as NEW PT presents with.... Ironically no previouscrecord is not enough as even if you moonlight in an er or othr practice you cannot legally bill a new pt if you have seen them in last 3 years....dont get me started.

Thanks for the feedback.
I appreciate your input. I thought like Steven sugested ,adding in CC or in HPI .This would cover the issue but it is cumbersome. I hope AC would have a check box to indicate that this a new patient or established patient, that would show on paper. It would be much easier even for coding.

I use a template for the HPI that goes "%MR %Lname presents on this initial visit to establish care". One of the few templates I use, and about as easy as a checkbox.

One of the few templates? You are missing out David. I change around the templates some but those things are huge time savers...huge

Travis, I have a "thing" about templates. I have seen way too many truly horrible records, and histories that were "close enough for government work" but not really accurate because that was the available templates. Dragon works fine for me. It seems disrespectful to me to treat my patient's concerns with a template, and I have no worries about an auditor suggesting I did not really do that much work.

I would appreciate if one help be and explain how to use or creat a template using % as mentioned above.

See this post:
http://amazingcharts.com/ub/ubbthreads.php/topics/31162/Conditional_Text#Post31162

Then, simply make a template using one of these placeholders in the right spot. AC then automatically fills in the correct information from the demographics page. For example, if you are in the record of Mr. James Smith, who is 49 years old, and your HPI template says " %Mr %FNAME %LNAME is a %AGE year old %sex..." and then click on that template, what will show up in the HPI is "Mr. James Smith is a 49 year old man..."

Thanks David
I will try to creat a template using thse placeholders. I let you know If I have any problem.
Thanks again.

Oh I still add in my normal things that I used to dictate like "he wants to go to DisneyWorld in July so would like to have the operation as soon as possible". So that's where Dragon comes in.

Templates rock for: "He had RUQ abdominal pain that was intermittent. Some nausea/vomiting. Has had several episodes. No fever or chills"

To each his own...that's why I like AC