If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Is it acceptable to use 'noncontributory, unremarkable or negative' when reporting past, family or social history?
Answer:
No, because the statement 'noncontributory, unremarkable or negative' does not indicate what was addressed. Did the nurse or physician ask specific conditions (i.e., any family history of coronary artery disease)? If for some reason you cannot obtain the family history, the documentation must support the reason why (e.g., the patient was adopted).
As you know, the ROS in an inventory of the negative/pertinent findings. "Unremarkable", to me, does not provide a positive/negative finding. I strongly recommend that once the provider records his findings, he documents a statment something like... "All other systems were reviewed and are negative." This is, of course, if the information was actually reviewed and pertinent to the reason for visit/chief complaint. E/M University has some other helpful hints...