Pain Scale

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Shoshana
Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Fri Sep 15, 2017 2:54 pm

If the pain scale is entered by the ancillary staff along with the vitals on the EHR, does the physician get credit for reviewing it if it is not discussed in his HPI or assessment/plan?

Pain Scale
Pain Scale used: 0-10 numeric scale
Pain Score: 10 (right flank to lower abdomen)

The ROS states Musculoskeletal: Reports: Flank pain (right)

No pain discussed in exam. CVA tenderness: none

Assessment/Plan states: Will schedule rt. URS with laser lithotripsy on Coumadin due to h/o DVT/PE
Risks of bleeding discussed and patient is willing to proceed.
Diflucan for yeast infection.
F/U at time of surgery.
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admin
Site Admin
Posts: 443
Joined: Mon Apr 09, 2012 1:54 pm

Thu Sep 21, 2017 10:42 am

Sure. The provider is not required to do the vitals and I would also consider the same if the pain scale is being reported as a vital. If used in the HPI- as long as the provider regurgitates it that would be fine.

- Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
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