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E/M Levels

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nyyankees

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with a young patient (i.e. 2-4 months) how do you capture History (Personal fx, social). I can see family but is it difficukt to get all 3?
 
The 95 and 97 documentation guidelines specifically cover this topic in detail.
Please take a look there and you'll have your answer. I'm on vacation and just thought I'd take a look at the forums.
 
an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.


I hope the above info is helpful.K
 
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