Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?

Answer
It is not acceptable to document "noncontributory, unremarkable or negative." Because these statements do not indicate what was addressed.

If a physician is unable to obtain the history component from a patient or from another source, the patient’s medical record should reflect the reason why the patient's condition or other circumstance are preventing the medical professional from obtaining the patient’s history.

For example, the patient was adopted. No medical records obtainable from adoption agency or other medical facilities.

Resources: CMS MLN Evaluation and Management Services Guide.

 

 

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