Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?
No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).
E/M Documentation Guidelines
last updated on 12/14/2011
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