Which component is NOT found in the history section of an E/M?

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Prepare for the AAPC CEMC Exam. Utilize flashcards and multiple-choice questions with detailed explanations and hints. Equip yourself for success!

The physical examination results are not included in the history section of an Evaluation and Management (E/M) encounter. The history section is specifically designed to gather information about the patient’s current health status, including their symptoms, medical history, and relevant background.

The chief complaint offers insight into the reason for the patient's visit. The review of systems (ROS) involves a systematic approach to inquire about various body systems and identify symptoms that may not have been mentioned during the chief complaint. Additionally, the past, family, and social history (PFSH) provides context regarding the patient’s medical background, family health issues, and social circumstances that may affect their health.

In contrast, the physical examination results document the findings from the clinician's assessment of the patient, which falls under a different section of the E/M documentation. This separation allows for a clear distinction between the subjective information gathered from the patient and the objective findings observed by the clinician.

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