E/M Weekly Tip: History Component "Unable to Obtain"

Per CMS guidelines, "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history."

The documentation must clearly reflect:

  • The components that were unobtainable (HPI, ROS and/or PFSH)
  • Circumstances that preclude obtaining the HPI, ROS, and PFSH (dementia, sedated on a vent, etc.). When using "poor" historian the documentation must support why (e.g., dementia).
  • Attempt to obtain from other resources:
    • A family member, spouse, nurse, etc., was not present or was unable to provide additional information
    • The medical record (chart, ambulance run sheet, etc.) did not contain the information needed

If patient or family can provide information at a later time, the provider may add an addendum containing this information.

Resources: CMS 1995 & 1997 E/M Guidelines.