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Family History in a EMR

  1. #1
    Default Family History in a EMR
    Medical Coding Books
    In our EMR system we have a history tab that past medical, social and family history are entered into. For the initital visit, that infomation is also entered on the note for that day. For subsequent visits, the nurses or MA's update that info while rooming the patient. Then verified by the provider. Does the note for subsequent visits also need to have the history info printed in it for that day. Is it acceptable to be in the history tab only? With the physician stating "Past medical, Social and Family history are reviewed and updated today".

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Need to reference location of information
    It's fine just to say you reviewed/updated the history today ... But ... Big, Red, BUT ... you need to also point to where it is to be found in the chart.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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