decisionhealth Newsletters, Answer Books - 2009 Issue 10 (October)
Physical Examinations-Histories / How to Document History
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Article Overview
This premium article covers how to document patient history in a way that supports evaluation and management recordkeeping. It is aimed at clinicians, coders, and documentation staff who need a plain-language overview of CMS expectations for progress notes, narrative history content, and the role of history within broader E/M documentation guidance.
Why This Topic Matters
Clear history documentation helps ensure the medical record stands on its own and supports accurate evaluation and management reporting. Understanding the general CMS framework can improve completeness, consistency, and compliance in documentation review.
What You Will Learn
- How patient history documentation fits into a progress note
- What CMS expects from self-contained visit documentation
- How narrative history relates to evaluation and management documentation
- The general role of history within broader E/M guidelines
Who Should Read This
- Physicians
- Nurse practitioners
- Physician assistants
- Medical coders
- Clinical documentation specialists
- Billing staff
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