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.
Disclaimer: All original material and images included on this website are the sole property of CMC EM Residency and cannot be used or reproduced without written permission. Information contained on this website is the opinion of the authors and does not necessarily represent the official opinion of Atrium Health or Carolinas Emergency Medicine Residency.
For Health Care Providers: Every effort is made to provide the most up to date evidence based medicine. However, this content may not necessarily reflect the standard of care and application of material contained on this website is at the discretion of the practitioner to verify for accuracy.
For the Public: This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Relying on information contained on this website is done at your own risk. Do not disregard professional medical advice or delay seeking care secondary to content on this website. Call 911 or seek a medical professional immediately for any medical emergencies.
Like us on Facebook or
follow us on Twitter/Instagram
Department of Emergency Medicine
Medical Education Building., Third floor
1000 Blythe Blvd.
Charlotte, NC 28203