Lunch and Learn – March 2017
What does a clinician need to document in the history? Is it okay to say, “non-contributory”? What if the medical assistant takes the HPI and the physician or nurse practitioner notes that it was reviewed?
This short video addresses the documentation guidelines for the History component of evaluation and management services including, HPI (history of present illness), ROS (review of systems) and PFSH (past medical, family and social history).
It will be helpful for physicians and other providers, as well as coders and auditors.Subscribe to lunch and learn for access to our monthly video series and bonus resources. Annual subscription is only $120.00.
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