Practice Management Alert

Sometimes a little extra documentation can go a long way toward justifying a higher level of service - and documentation of PFSH is no exception.
 
Many times a physician will flip back in an established patient's chart and quickly review the original patient intake forms that include the patient's past, family, and social history (PFSH). The physician may ask questions such as "Has anything changed since you completed this form?" or "Are you still married?" or "Do you still smoke?" and make notations accordingly.
 
Such a review can qualify as a complete PFSH - a component necessary to justify a comprehensive history, which in turn can contribute to a higher-level E/M service. But you cannot count this information if the physician doesn't make a summary notation of the new PFSH review and reference the exact location (patient intake form) and date (when patient completed the form) of the original patient PFSH, says Curtis J. Udell, CPAR, CPC, CMPA, senior advisor with Health Care Advisors Inc. in Annandale, Va.
 
Help your physician: Make documenting a review of PFSH easy for your physician by including two boxes on your medical record form that your physician can check if applicable:

 

The first box should say, "PFSH reviewed and unchanged as documented," and the second should say, "All other PFSH items reviewed are unchanged as documented."

 

Next to each statement should be a space to reference the location and date of the original PFSH and a line for the physician's signature, Udell says.

 

If the physician wishes to indicate a review of a patient's PFSH with no changes, he can check the first box.

 

If there are some changes to the PFSH, the physician can check the second box and then document the changes separately.