Starting in 2018 Centers for Medicare and Medicaid {CMS} Services in conjunction with the American Medical Association {AMA} recognized the need to reduce documentation requirements for providers (physicians and non-physician practitioners). In 2019, the History component consist of three requirements of Chief Compliant (CC) {reason for the visit}, History of Present Illness {HPI} and Review of Systems (ROS) noting information needs to relevant to the Chief Compliant. They approved of allowing the patient, caregiver, or ancillary staff to document the patient’s History in conjunction that the provider would review the information for relevancy while also documenting the provider reviewed stated patient information at the visit.
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