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1997 Documentation Guidelines for Evaluation and ...

1997 Documentation Guidelines for Evaluation and Management Services 1. TABLE OF CONTENTS. Introduction ..2. What Is Documentation and Why Is it Important? ..2. What Do Payers Want and Why? ..2. General Principles of Medical Record Documentation ..3. Documentation of E/M Services ..4. Documentation of History ..5. Chief Complaint (CC) ..6. History of Present Illness (HPI) ..7. Review of Systems (ROS) ..8. Past, Family and/or Social History (PFSH) ..9. Documentation of Examination ..10. General Multi-System Examinations ..11. Single Organ System Examinations ..12. Content and Documentation Requirements ..13. General Multi-System Examination.

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