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•A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years

•An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years

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Integumentary – skin / breast

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•Past history

• Patient's past experiences with illnesses

• Operations

• Injuries

• Treatments

•Family history

• Review of medical events in patient's family

• Hereditary diseases

• Diseases that may place patient at risk

•Social history

• Age appropriate review of past/current activities

• Smoking or other tobacco use

• Alcohol use

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• Abusive situations etc

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IOP‐ Intraocular PressureSLE‐ Slit Lamp ExamDFE‐ Dilated Fundus ExamEOM‐ Extraocular Muscle Function

Test visual acuity (Does not include refraction) Gross visual field testing by confrontationTest ocular motility include primary gaze alignment Inspection of bulbar/palpebral conjunctivae Examination of

• Ocular adnexae including lids (eg, ptosis or lagophthalmos),

• Lacrimal glands, lacrimal drainage, orbits • Preauricular lymph nodes

•Examination of pupils/irises• Shape• Direct and consensual reaction (afferent pupil)• Size (eg, anisocoria)• Morphology

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•Slit lamp examination•Corneas

• Epithelium• Stroma• Endothelium• Tear film

•Anterior chambers• Depth• Cells• Flare

•Lenses• Clarity• Anterior and posterior capsule• Cortex• Nucleus

• Measurement of intraocular pressures• Except in children or in trauma or infectious disease

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Ophthalmoscopic examination• through dilated pupils (unless contraindicated)

•Optic discs• Size• C/D ratio• Appearance (eg, atrophy, cupping,tumor elevation)• Nerve fiber layer

Posterior segments• Retina • Vessels (eg, exudates and Hemorrhages)

PLUS - Orientation to time place person

OR- Mood and affect (eg, depression,

anxiety, agitation)

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•Problem oriented

•1-5 elements

•Expanded problem oriented

•6 elements

•Detailed

•9 elements

•Comprehensive

•14 elements*

•* all elements plus one Mood or orientation

Number of possible diagnoses-management options that must be considered

Amount-complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed

Risk of significant complications, morbidity and/or mortality

Comorbidities, associated with the patient's presenting problem(s), diagnostic procedure(s) and/or possible management options

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Time is key when counseling and care coordination are the primary component (more than 50%)

MUST document carefully when using time

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Straight forward

Minimum number diagnoses

Minimal management options

Minimal risk

Low complexity

Limited number of diagnoses

Limited management options

Low risk

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•Moderate Complexity

• Multiple diagnoses

• Moderate management options

• Moderate risk

•High Complexity

• Extensive number diagnoses

• Extensive management options

• High risk

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•Minimal

• Presenting problem(s)

•One self-limiting or minor problem

• Diagnostic procedures

•Simple testing to order (blood test)

• Management options

•Simple comfort measures

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•Low• Presenting problem(s)

• Two or more self-limiting or minor• One stable chronic• Acute, uncomplicated illness

• Diagnostic procedures• Bit more complicated testing

• Management options• OTC meds• PT or OT

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•Moderate

•Presenting problem(s)

•1+chronic with exacerbation/2+ stable chronic

•Undiagnosed new problem

•Acute with systemic sx

•Acute complicated injury

•Diagnostic procedures

•More complicated options with higher risk

•Management options

•Rx meds

•Minor surgery

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•High• Presenting problem(s)

•1+chronic/severe exacerbation•Acute/chronic illness with risk•Abrupt neurologic status change

• Diagnostic procedures•Extremely complicated testing

• Management options•Major surgery•IV medications•DNR decision

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•What is cloning?•‘Cloning‘ = documentation worded exactly like previous entries

• may also refer to 'cut and paste' or 'carried forward' in electronic records

• may be handwritten•These methods of documenting are acceptable BUT

• not be expected same patient had same exact problem, symptoms, and required same treatment

• Not expected same patient had same problem/situation on every encounter.

•Cloned documentation does not meet medical necessity•Identification of cloned documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made

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