1995 Evaluation and Management Documentation Guidelines

Why This Topic Matters

Accurate documentation is central to supporting evaluation and management reporting, claim review, and medical record integrity. This article helps readers understand the structure and scope of the 1995 guidelines used in E/M coding and review.

Article Sections

1. Introduction

   Introduces the purpose of medical record documentation and why payers and providers rely on it. Summarizes the role of documentation in care continuity, review, and record support.

2. General Principles of Medical Record Documentation

   Presents broad documentation principles that apply across medical and surgical services. Describes the general expectations for record completeness, accessibility, and support for reported services.

3. Documentation of E/M Services

   Explains how evaluation and management services are organized in the 1995 framework. Introduces the major components discussed later in the article and notes how documentation may vary by patient group and service type.

4. Documentation of History

   Covers the structure and categories of history used in E/M services. Describes the major history elements and how they are presented in the guideline.

5. Chief Complaint (CC)

   Defines the chief complaint as a documentation element within the history section. Focuses on its role in identifying the reason for the encounter.

6. History of Present Illness (HPI)

   Discusses the present-illness narrative as part of the history component. Outlines the broad information categories associated with describing the patient’s current condition.

7. Review of Systems (ROS)

   Describes the review of systems as a systematic inventory of body systems. Summarizes how the guideline organizes this part of the record.

8. Past, Family and/or Social History (PFSH)

   Addresses the past, family, and social history portion of the documentation framework. Notes how this information is considered across different E/M settings.

9. Documentation of Examination

   Describes the examination component used in E/M documentation. Summarizes the general categories of exam structure and the body areas or organ systems referenced.

10. Documentation of the Complexity of Medical Decision Making

    Introduces the medical decision-making component of the guideline. Explains the broad factors used to characterize complexity and how they are organized in the article.

11. Number of Diagnoses or Management Options

    Discusses one of the main factors contributing to medical decision making. Focuses on how the guideline frames the scope of problems and management considerations.

12. Amount and/or Complexity of Data to be Reviewed

    Covers the data-review portion of medical decision making. Summarizes the types of record review and information-gathering discussed in the guideline.

13. Risk of Significant Complications, Morbidity, and/or Mortality

    Addresses the risk component used in assessing medical decision making. Includes the article’s broad discussion of presenting problems, procedures, and management options.

14. Table of Risk

    Presents a structured risk table used within the documentation guidance. Organizes examples by general risk level across presenting problems, diagnostic procedures, and management options.

15. Documentation of an Encounter Dominated by Counseling or Coordination of Care

    Explains how encounters dominated by counseling or coordination of care are treated within the documentation framework. Summarizes the role of time as a controlling factor in these visits.