What To Do When Your Patient Is a “Poor Historian”

Clear and comprehensive documentation is a critical element in getting claims paid. You hear that advice day in and day out. So what do you do when the provider is unable to obtain a critical component of documentation from a patient? The answer isn’t as tricky as you might think.

When a provider is unable to obtain certain medical information, he or she should clearly document in the record:

Evaluation and Management – CEMC

  • The components that were unobtainable (for example, the history of present illness (HPI); and
  • Circumstances that precluded obtaining the specific documentation. For example, “The patient was unconscious.” Or, “The patient was a ‘poor historian’ due to advanced dementia.”

Before giving up the ship, however, the provider should attempt to obtain the information from another source, such as a family member, spouse, medical record, etc. If these sources were unable to supply the missing information, the attempt should be documented as well. For example:

  • “A family member was contacted, but unable to provide additional information.” Or,
  • “The medical record did not contain the needed information.”

If, at a later time, the patient or some other source is able to supply the missing information, the provider may add an addendum to the record to fill in the missing blanks that support medical necessity for the provided services.

Resource: The Centers for Medicare & Medicaid Services 1995 and 1997 Documentation Guidelines for Evaluation and Management Services

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 426 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

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