DecisionHealth, DecisionHealth - 2014 Issue 10 (October)

Don’t skip entering patients’ history when documenting E/Ms in new EHR

Question: In a new electronic health record (EHR) system, when a patient doesn’t have a medical history, the medical history portion just shows up blank. The physicians in my practice want to know if they click “verify” on the note (aka verifying no medical history), will that still satisfy requirements for the E/M documentation?

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