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Wiki Hx "unchanged"

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LindaEV

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Local Chapter Officer
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Doctor documents "social history unchanged" and "no recent changes in medical history"

I know he should be putting the date of the history he reviewed/compared to...but in an audit can you count this at all?
 
Established patient

As an established patient, you only need to meet two out of the three key elements. Hope the exam and MDM are enough to get the level of service.

I would not count these statements without reference to the original documentation by date and location (Example of statement I would count: "Social history unchanged since office visit of 4-12-09" or "Past Medical History updated with latest hospitalization on 11-18-09" )

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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