Documenting Past Medical History.
When documenting Past Medical History, there is a tendency to document with the prefix : "History of ..."
Although this is very appropriate for a lot of diagnoses that have resolved or are limited in time, ex:
History of Pneumonia
the same may not apply for an ongoing chronic condition, such as:
History of Diabetes or History of Hypertension, unless the condition has truly resolved.
Most coders can discern the difference between the two documentation types, however, it is much better to remove the confusion and ambiguity and documenting clearly.
When documenting Past Medical History, there is a tendency to document with the prefix : "History of ..."
Although this is very appropriate for a lot of diagnoses that have resolved or are limited in time, ex:
History of Pneumonia
the same may not apply for an ongoing chronic condition, such as:
History of Diabetes or History of Hypertension, unless the condition has truly resolved.
Most coders can discern the difference between the two documentation types, however, it is much better to remove the confusion and ambiguity and documenting clearly.
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