Documentation of status crucial to HPI “3 chronics” caveat

Article Overview

This article addresses evaluation and management documentation guidance for the history of present illness, focusing on how chronic conditions are documented and counted under the 1995 and 1997 E/M guidelines. It is intended for coders, auditors, and clinical documentation staff who review office and outpatient encounter notes. The piece also covers the role of ancillary staff and students in documenting parts of the medical record, along with CMS teaching physician documentation expectations and referenced official resources.