Understanding E/M: Don’t bypass family history in your E/M documentation

Why This Topic Matters

Incomplete family-history documentation can weaken the support for an E/M note during review or audit. Understanding what belongs in this part of the record helps practices reduce avoidable documentation denials and improve compliance with documentation standards.

Article Sections

1. Family history in E/M documentation

   Introduces the importance of recording family history as part of the patient record and explains why this section is commonly left incomplete. It frames the documentation issue in the context of E/M services and compliance.

2. Be thorough, be specific

   Discusses the need for more complete family-history entries and notes that practices may use intake forms and ongoing follow-up to collect information. It also addresses documentation of review, unavailable history, and later updates to prior history elements.

3. Be mindful of what you say

   Focuses on the wording used in family-history documentation and the importance of showing that the information was actually obtained and reviewed. It also highlights how auditors may evaluate this portion of the note.

4. ‘Great example of how to do it right’

   Presents a brief audit-oriented example showing a note that appropriately captures family-history information in a clinical encounter. The example is used to illustrate documentation quality in general terms.