AAPC Certified Professional Medical Auditor (CPMA) Practice Exam

The selection of review of systems and past family or social history as the correct answer is based on the fact that these elements can indeed be documented by staff members or other healthcare professionals who are not the primary provider delivering the evaluation and management (E/M) service. In clinical practice, the review of systems typically involves gathering information from the patient about other bodily systems and their potential issues, which can be efficiently collected through a questionnaire or a structured interview performed by medical assistants or other trained staff. Similarly, past family or social history can be obtained during patient intake by staff trained to gather such information.

This approach allows the provider to focus on the examination and critical decision-making aspects of the visit, while still ensuring that comprehensive patient history is captured accurately. Both this information is considered supplementary to the subjective information that impacts the provider's clinical judgment during the visit.

In contrast, elements such as the chief complaint and examination findings generally need to be documented by the provider themselves. This is due to their direct involvement in interpreting the patient's concerns and findings during the physical examination. Diagnosis and treatment plans also require the provider's clinical expertise and decision-making, which necessitates documentation by the individual who has evaluated the patient directly.

Referral information and follow-up actions involve the provider's clinical