This is the case for some elements of history. Under the 1995 and 1997 documentation guidelines for evaluation and management (E/M) services, you can refer to, and update or indicate no changes to, the documented review of systems or past, family, or social history rather than redocument that information. However, you should document the reason for your encounter (ie, chief complaint) and the interval history of present illness (HPI) that you obtain.

When selecting the level of history that includes information documented by another individual, consider only the information that you verified or updated. You should also document the date and location of the information that was reviewed. It is helpful to note items that affect your medical decision-making (eg, “I reviewed Dr Smith’s note from earlier today and agree with her documented review of systems including patient’s continued headache and nausea, which are inconsistent with the reported injury.”).


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