Evaluation & Management services

Family History

Can provider write Unobtainable under Family History? Is this an acceptable comment? Per provider patient unable to answer question and no family members around to ask.

ROS

Provider in his report has an extensive 13-point review of systems were obtained and is unremarkable except for that described in the History of Present Illness. Found patient questionaire but it's dated 7/28/10 and patient was seen 2/7/11.
Should patient's questionaire be a current one?

Thanks for your help.

yes, no

You can count "unobtainable" for FH and ROS

"ROS negative except as in HPI" is open to debate- I think most consider it counting for a full ROS since we assume that the doctor did what she documented.