Wiki Past Medical History Question

[wbrodsky]

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.

 

[tag60]

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.

 

[cgaston]

I agree with tag60.

The only time I give zero is if the field is blank.

 

[nomerz]

Agree, I would count it, as the provider attempted to get PMH and there is none.