decisionhealth Newsletters, Part B News - 2005 Issue 2 (February)
Make sure old, new E/M documentation tell same story
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Article Overview
This article discusses documentation practices for evaluation and management visits, focusing on how clinicians and coding staff can carry forward review of systems and past family and social history information while keeping it current and internally consistent. It explains why updated documentation matters, who should review it, and the general recordkeeping practices that help avoid conflicts between older and newer notes.
Why This Topic Matters
Accurate, consistent E/M documentation supports compliant medical records and helps prevent contradictions that can create audit risk or confusion for later reviewers.
What You Will Learn
- How prior visit documentation may be incorporated into a later E/M note
- Why current review and updating of patient history elements matters
- General recordkeeping practices that help keep documentation consistent over time
- Why clinicians may choose to set their own update intervals for reused history information
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Documentation specialists
- Practice managers
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