¶ … Management Services:
The determination of the suitable level of services provided during a patient's visit normally requires the identification of whether the patient is new or already established to the hospital. This is followed by the clinician's use of the presenting illness and clinical judgment as leading factors that help in identifying the extent of care services to be carried out based on the condition of the patient. In addition to this, there are key components and contributing factors that are used in the determination of the level of evaluation and management services provided to the specific patient.
Key Components and the Contributing Factors:
While a clinician can use the presenting illness and clinical judgment in evaluation and management of patients' services, there are key components and contributing factors that can also be utilized. Actually the documentation of evaluation and management services is usually based on these components ("Introduction and Definitions," n.d.). These vital elements of service and documentation that are used in counseling and coordination of patient care include:
History:
History is one of the most important parts of determining the level of evaluation and management services offered to a new or already established patient. The history is developed to act as a narrative that provides information regarding the medical problems and symptoms being tackled during the encounter. According to the guidelines of evaluation and management of services, there...
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