decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Documentation of history
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Article Overview
This page explains the 1995 E/M documentation framework for history, focusing on the structure of the history elements and the documentation expectations associated with them. It is useful for coders, auditors, clinicians, and documentation specialists who need a public overview of how history documentation is organized and what topics the full guidance addresses. The article also touches on when information may be updated, recorded by others, or unavailable because of the patient’s condition.
Why This Topic Matters
History documentation is a core component of E/M reporting, and understanding the framework helps users evaluate whether the full article is relevant to documentation, audit preparation, or training.
Article Sections
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History elements and levels
Introduces the major components of history documentation and the broad levels used in the 1995 E/M framework. Summarizes how those elements are organized across different history types.
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Documentation guidelines
Provides general guidance on documenting history information across encounters and settings. Covers how history information may be reviewed, updated, or recorded by others, as well as what to do when history cannot be obtained.
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Definitions and specific documentation guidelines
Points to the more detailed definitions and documentation guidance associated with the individual history elements. This section serves as the bridge to the expanded reference material that follows in the full article.
What You Will Learn
- The major components that make up patient history documentation
- How the 1995 E/M history framework is organized at a high level
- General documentation expectations for history information across encounters
- Situations where history information may come from prior records or other sources
- What kinds of topics are covered in the detailed element-by-element guidance
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Auditors
- Physicians and other clinicians
- Billing staff
- Coding educators
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