Question

Tyler Martin, a third year Tyler Martin, a third-year medical student on a family practice clerkship, was directed to obtain a comprehensive H&P of a new patient: D. A. D. A. recently moved to your city and has never been seen at this practice. She comes in today  to  establish care, and she is complaining of a cough. Followingis the student's documentation of the comprehensive H&P. As you read it, keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS for information that should be included in a medical record. Refer to the H&P to answer the questions that follow.

1.  Does this document meet the CMS guidelines for documentation of a comprehensive H&P? Why or why not?

Answer 1

Does this document meet the CMS guidelines for documentation of a comprehensive H&P? Why or why not?

No, this document doesn't meet the CMS guidelines for documentation of a comprehensive H&P.

CMS is simplifying documentation in two ways:

• [W]hen relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.
• [P]ractitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.