Wiki PFSH Question-I would like

[mrbrooks]

I would like to know any thoughts on the Phrase " History reviewed: No pertinent past medical history" acceptable or not acceptable documentation? Thank you.

 

[olivers]

Pfsh

I definitely believe this to be unacceptable documentation. If you look at an audit form, you will see the "bullets" that have to be addressed.

 

[macjac7]

I would like to know any thoughts on the Phrase " History reviewed: No pertinent past medical history" acceptable or not acceptable documentation? Thank you.

I give credit if the physician states that family history has been reviewed and non- contributory (or other wording) but it must state reviewed. I do let the physician know that it is best to have something. If a patient presents with a sore thumb or cold you really do not need a family history.
As far as the medical history, can you pull something like a med list, allergies should be noted or stated NKDA, social history does the patient smoke, drink, married, school.
Hope this helps- Jackie

 

[mrbrooks]

Thank you Jackie and Sharon, I really appreciate your advice. I have been going back and forth on this phrase and am glad to hear some other opinions.

 

[PVAzCPC]

I would like to know any thoughts on the Phrase " History reviewed: No pertinent past medical history" acceptable or not acceptable documentation? Thank you.

Past medical history is only one component of PFSH; if, for instance, a child, it's possible that there is no pertinent past medical history. IMO: this would be acceptable for what it is; are the other 2 components addressed at all? (family medical, social)