What constitutes a properly documented examination according to the guidelines?

A properly documented examination according to the guidelines requires a comprehensive approach that includes both the patient’s history and any relevant changes observed during the visit. This ensures that the examination is not only reflective of the physician’s findings but also provides a context for those findings through the patient's medical history and present conditions.

Incorporating patient history plays a crucial role in understanding the patient's current health status and assists in formulating an accurate diagnosis and treatment plan. Thus, when any changes during the visit are documented, they add to the continuity of care by showing progress or setbacks in the patient's health.

While documenting only the findings noted by the provider lacks crucial context, an overall summary of past history may leave out significant changes observed during the current examination. Similarly, individual notes from family members, while potentially informative, do not replace the need for a thorough examination and would not encapsulate the full scope of the patient’s current health status. Therefore, the combination of patient history and the updates noted during the visit constitutes a complete and compliant documentation method.