decisionhealth Newsletters, Part B News - 2014 Issue 10 (October)
Don’t skip entering patients’ history when documenting E/Ms in new EHR
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Article Overview
This article addresses documentation practices for evaluation and management records in a new electronic health record system, with emphasis on how patient history should be captured when portions of the history are absent. It is relevant to coders, compliance staff, and clinicians who document E/M services, and it highlights the importance of carrier-specific documentation expectations.
Why This Topic Matters
Accurate E/M documentation supports compliant recordkeeping and helps avoid omissions when history fields are left blank in an EHR. The article focuses on general documentation considerations for patient history and related practice procedures.
What You Will Learn
- How patient history documentation may be handled in a new EHR workflow
- What types of history information are generally important to capture in E/M notes
- Why carrier-specific documentation requirements may matter
- How documentation expectations can differ for established patients
Who Should Read This
- Physicians
- Coders
- Clinical documentation staff
- Compliance staff
- Practice managers
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