When the history of present illness (HPI), review of systems (ROS) and past/family/social history (PFSH) are unobtainable, does a physician have to document the reason why, or can it be inferred by other documentation within the HPI (e.g., patient had severe dementia)?

The documentation must clearly reflect:

  • The components that were unobtainable (HPI, ROS and PFSH)
  • Circumstances that preclude obtaining the HPI, ROS and OFSH (dementia, sedated or a vent, etc.). When using "poor historian" the documentation must support why (e.g., dementia).
  • Attempt to obtain from other resources:
    • No family members were present to provide information
    • The medical record (chart, ambulance run sheet, etc.) did not contain the information needed
    • If patient or family can provide information later, the provider may add an addendum containing information.

Resource: CMS MLN Evaluation and Management Services Guide.

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