By Jan Deyber, CRN-C, and Tiffany Brookshire, BSN, CRN-C

We often see inconsistency in medical records regarding diagnoses as current or historical. Documenting “history of” when referencing a patient’s past medical background is a longstanding practice.  Providers may intend a “present perfect” tense – a condition that started in the past and continues in the present.  However, in the world of diagnosis coding, “history of” indicates a past (or past perfect) tense; in other words, a condition that no longer…

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