Best Practices for Capturing Patient History

An accurate patient history (medical, surgical, family and social) aids providers in their assessment and decision-making and improves E&M coding.

Unfortunately many practices deploy this in a manner that leads to “chart overpopulation” and possible inconsistencies in the chart.  Some recommended best practices:

  1. Customize your history form to include only the information that is pertinent to your specialty and practice.  If you don’t USE the information it is best left off.
  2. Whenever possible use checkboxes or yes/no answers and limit narrative to only items requiring further explanation.
  3. Make sure the history section of your EHR matches your paper form exactly.
    • If your EHR’s Patient Portal allows you to deploy your history form through the portal take advantage of this.  It will be easier for your patients and staff and eliminate the possibility of an error transcribing the information.
  4. Develop a policy and process for updates:
    • Since most EHRs carry history forward and you receive E&M credit for updating history, you may only want patients to complete the full form once and then update with them verbally at subsequent visits.  
    • If you deploy your history form through the Patient Portal how will you address patients that did not complete it?
  5. Consider updating the patient’s active diagnosis at the same time you add/update their history (this is another reason for using checkboxes – the checkboxes can be tied to diagnosis codes)
    • For example, if a patient has a history of blood clots, the I80.x ICD-10 can be added to their problem list.
  6. If available in your EHR, take advantage of “private” history section that allows you to document information you don’t want showing up in notes or if the chart is exported or printed.  

Having succinct, timely history that is easily usable by the provider will allow them to make the most informed medical decisions for the patients, with the added benefit of maximizing E&M visit codes.