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EVALUATION AND MANAGEMENT DOCUMENTATION Marc R. Newer, MD University of California, Los Angeles, CA INTRODUCTION: Most patients visits with their doctor are called Evaluation and Management (E/M)
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Evaluation and management documentation refers to the process of recording a patient's medical history, performing a physical examination, and documenting the medical decision-making involved in their care.
Physicians, nurse practitioners, physician assistants, and other healthcare providers are required to file evaluation and management documentation for each patient encounter.
Evaluation and management documentation should be filled out accurately by documenting the patient's complaints, history of present illness, physical examination findings, medical decision-making, and treatment plan.
The purpose of evaluation and management documentation is to provide a record of the patient's visit, justify the medical necessity of the services provided, and ensure proper reimbursement for healthcare services.
Evaluation and management documentation must include details on the patient's chief complaint, history of present illness, review of systems, past medical history, family history, social history, physical examination findings, medical decision-making, and treatment plan.
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