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Wiki Independent Historian

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blaymon

Networker
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Winston Salem, NC
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Quick question: Does the provider need to document an independent historian provided the history of present illness to meet the criteria for independent historian? Example: "Mom is with patient and providing the HPI." I know it can be inferred if the patient is 8 months old but probably a good idea to provide documentation. Thank you!
 
per Novitas:

Documentation must support the reason the patient is unable to provide the complete or reliable history, and from whom the practitioner obtained the additional history.
 
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