How to Document a Patient’s Medical History

The key purpose of complete and accurate documentation in the medical record is to foster a culture of quality and continuity of patient care. Complete and accurate documentation creates thorough communication among providers, their staff and, ultimately, the patient for preventive health services, treatment, planning and delivery of care. When evaluating documentation for the history component of an E/M service, it is important to remember:

1. A chief complaint is a medically necessary reason for the patient to be in the office. An identifiable CC is the first step in establishing medical necessity. A visit may be denied in an audit without a CC.
2. If documentation substantiates that the provider is unable to obtain a history from the patient or other source (e.g., the patient is unconscious), the provider will not be penalized, and the overall level of medical necessity and/or provider work will not be discounted automatically.
3. In the event that additional history is provided by a family member or caregiver and documented by the provider, it can be credited toward the medical decision-making component of the service.
4. Past family and social history documented from a previous encounter may be cited without redocumentation for most payers. The provider should indicate the new status of the history and note where the original documentation may be found.

Although there are many nuances to the elements of the HPI component, understanding how to correctly document the patient’s history will put you on the right path to attain the correct coding level for each patient encounter. Documentation must reflect medical necessity for services to support the level of coding.

For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC‑I, CPC, CRHC, CHA, at 404-633-3777 x820 or via email at [email protected].

Reference

1. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Evaluation and Management Services (ICN 006764). 2016 Aug.

Editor’s note: In June on the Practice Page, we ran part 1 of a series, “Medical Decision Making Component.” Look for part 2 in the September issue.