Question: I've heard that for an E/M visit, the physician is responsible for certain parts of that visit. Does Medicare state this explicitly? California Subscriber Answer: In the E/M service documentation guidelines, CMS states that ancillary staff or even the patient (via questionnaire) may record the review of systems (ROS) and past, family, and/or social history (PFSH) portions of the history component. Be careful: Straight from the source: The 1997 guidelines include the exact same wording as above. In addition, the 1997 guidelines refer to documentation by ancillary staff in another section, which describes requirements for the "constitutional" element of the exam: "Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)." You can download the documentation guidelines from http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp Watch out: