Independent Historian Should Be Clinically Necessary
Question: A patient came to an encounter with their spouse. Although the patient does not have dementia or any other condition that might limit or prohibit their participating in the encounter, the patient, according to the provider, stated that they wanted their spouse to “do the talking.” Can the spouse be considered an independent historian in this situation? New Mexico Subscriber Answer: No, an independent historian is clinically appropriate only for encounters where patients have a condition that prevents accurate or comprehensive communication. According to the AMA, an independent historian is “an individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.” When the assistance of an independent historian is necessary and appropriate, the patient’s history does not need to be provided in person but does need to be obtained directly from the independent historian. The AMA notes that interpreters or other people who provide translation services should not be considered independent historians. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
