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

Article Overview

This article covers documentation practices for evaluation and management (E/M) visits, with a focus on the family history portion of the patient record. It is aimed at clinicians, coders, auditors, and compliance staff who want to understand why family history is often missed, how documentation expectations are discussed in practice, and how guidance has been applied under different E/M documentation frameworks. The piece also touches on compliance concerns raised by auditors and references historical guideline differences relevant to E/M documentation.