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" history, 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