Those who fail to learn from history...

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"