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Do headings matter in an E/M note

March 30th, 2009 - Codapedia Editor
Categories:   Audits/Auditing   Documentation Guidelines   Primary Care|Family Care   Evaluation & Management (E/M)  
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When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define.  That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical, family and social history.  The auditor may use history found in any part of the history.  The ROS may be in a section labeled as ROS or it may be part of the HPI.  

When using an Electronic Health Record, there is often a function which tells the clinician what level of service is documented.  Keep in mind that this function will only work if the clinician uses the templates, and documents the history elements in the section with that label.

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