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Your documentation should cover: The specific problem addressed during the visit A medically appropriate history and/or examination, documented to the extent that's clinically relevant Your clinical assessment of the problem The management plan: continuing current treatment, recommending OTC options, providing reassurance, or giving basic follow-up instructions Any data reviewed, such as prior labs or records, including what you found One rule that's worth repeating: under current guidelines, history and examination don't select the code level

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[DOI] [PMC free article] [PubMed] [Google Scholar] 206.Clapham JC, Arch JR, Chapman H, et al