tci Part B Insider - 2016 Issue 7

Reader Question: You Can Carry Over PMFSH From Previous Encounter--to an Extent

Question: Our doctor documents the electronic medical record (EMR) really well in the history but not in the exam when he sees patients for follow-up visits (such as checking to see if bronchitis is resolved). He also just copies the past medical, family, and social history (PMFSH) from one visit to the next. Is this wrong? Answer: It could be. If your EHR consistently shows E/M documentation that is robust in one section (such as History) and thin in another (such as Exam), you may be trusting your software programming to do too much. Even if you’re seeing...

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