decisionhealth Newsletters, Coder Pink Sheets - 2003 Issue 11 (November)
Quick-tip for E/M:E/M Documentation: Date & sign for past history not enough
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Article Overview
This short article addresses evaluation and management (E/M) documentation practices for reusing prior review-of-systems and past/family/social history information in a current encounter note. It is aimed at physicians, coders, and documentation staff who need to understand the general expectations for updating and referencing earlier history entries without unnecessarily duplicating the entire record.
Why This Topic Matters
Proper E/M documentation supports accurate note integrity and helps providers maintain compliant, reviewable records when relying on prior history.
What You Will Learn
- How the article frames the use of prior history in E/M documentation
- What kinds of documentation elements are discussed for referencing earlier history
- Why this guidance matters for visit note preparation and record consistency
- How the topic relates to the 1997 E/M documentation guidelines
Who Should Read This
- Physicians
- Medical coders
- Medical documentation staff
- Compliance professionals
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