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Past,Social,Family history documentation

K

KoBee

Expert
Messages
455
hello everyone, i have a quick question. When a physician documents Past medical history: Denied. Is that acceptable documentation or not?
 
I'm going with not on this one. They are not going to get credit for that statement.

How can you deny having any past history? If the patient refused to answer that is different and should be stated as such then you would get credit.

Laura, CPC, CPMA, CEMC
 
"denied" seems pretty weak to me as well. It needs to be clear that the physician queried the patient about their history and I don't think that this example suffices.
 
I agree with the previous responses. If the patient refused or the Physician was unable to obtain hx due to the patients condition (must explain pt's condition, unresponsive, dementia, etc.), then these types of statements would be acceptable. This applies to both 95 & 97 guidelines.

Hope this helps!!!
 
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