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Thread: Family History in a EMR

  1. #1
    Join Date
    Apr 2007

    Default Family History in a EMR

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    Milwaukee WI

    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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