Reader Questions: Nonphysician Staff Can Perform History Element

Why This Topic Matters

Understanding who can document parts of the history and what the physician must verify helps practices support compliant E/M recordkeeping and avoid documentation gaps.

Article Sections

1. Question

   The article begins with a reader’s question about whether a surgeon must personally take the patient history or whether other staff may do so before the surgeon sees the patient.

2. Answer

   This section explains the roles of ancillary staff and clinicians in documenting history components and discusses physician review, sign-off, and related office visit documentation considerations.

3. Be careful

   This cautionary section highlights the need for physician attestation and review of charted history information in the context of office visit documentation and incident-to services.