For Past Medical/Surgical, Social, Family History:
"Negative," "noncontributory," "not significant," "unknown," or "reviewed in chart" are not considered sufficient to support these history components.
** For "unknown" you must clearly indicate a high acuity caveat or document if the patient is adopted.
*** Our coders do not reference nursing notes for "reviewed in chart." These must be imported into your power note for the coder to see it.
**** It is ok to say "No past medical history"
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.