Dear Medical Provider and staff,

This document is a universal PreHistory (PreHx) assembled through 501(c)(3) non-profit Patient Advocacy Initiatives. Please use this patient authored information to populate the History component of your health record encounter note.

Accepting this document and empowering the patient to co-author the medical record is supported Federally in three ways:

1. This PreHx is a patient’s written request to amend the medical records per the Standards for Privacy of Individually Identifiable Health Information of 2001 (HIPAA Privacy Rule) [45 C.F.R. § 164.526].
2. A patient authored History is defined as patient generated health data (PGHD) per the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) as part of the Act’s objective to coordinate care through patient engagement.
3. January 1, 2019 new Final Rule by the Centers for Medicare and Medicaid Services (CMS) allows ancillary staff and patients to enter the History into the health record. This Final Rule was declared November 23, 2018, p. 59653 in the Federal Register https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf

Through the “Patients Over Paperwork Initiative”, CMS aims to simplify medical record documentation. New laws and rules empower patients and ancillary medical staff members to populated the History. CMS wants medical providers to focus on the needs of the patient rather than be overwhelmed with clerical duties.

Patient Advocacy Initiatives, Pennsylvania, offers www.PreHx.com as a free service. All individual entered information is kept confidential and private. PreHx.com is a tool to help people prepare for medical encounters. We guide individuals through all of the near 30 medical interview questions as defined and structured by 1995 and 1997 CMS Evaluation & Management Documentation Guidelines.

This PreHx is intended to:

• Facilitate patient-provider communication
• Reduce medical provider clerical burden
• Improve health record documentation

Ancillary staff members can scan this patient authored PreHistory into your electronic health record (EHR) or enter a copy into your paper medical record. The provider should read the PreHx and document that it was reviewed. Rather than spend much of the visit gathering basic questions, start the visit with a finished History. Work at the top of your license!

Sincerely,
Michael J. Warner, DO, CPC, CPCO, CPMA, AAPC Fellow
President, Patient Advocacy Initiatives, drmichaelwarner@patientadvocacyinitiatives.org