Past Medical History Question

wbrodsky

Networker
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I am performing an audit and in the note under Past Medical History, the provider states "No Medical History". Can I count this in the HPI evaluation?

**I know we can but some coworkers are disagreeing with me. I need others to assist me in this fight.
 
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tag60

Guru
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It's my understanding that if provider attempted to get the information, then he/she should be given credit for it. It doesn't have to be a positive medical history for it to count. Provider did the work of gathering the information and documented the outcome.
 
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