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    Wiki Acceptable ROS/PFSH notation?

    My provider usually documents ROS/PFSH for establish patients as such: PAST MEDICAL HISTORY, SOCIAL HISTORY, MEDICATIONS AND ALLERGIES: Reviewed and not changed since last visit. REVIEW OF SYSTEMS: Reviewed in chart and signed. Per E/M guidelines, the provider has to indicate that the...
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    Wiki EMR/EHR documentation

    Our providers have started using canned text for PFSH. We are not sure why but are questioning the validity of this text. "Past medical, surgical, and family histories reviewed for relevance to current acute and chronic problems." We clinic coders do not feel this is sufficient documentation...
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    Wiki PFSH Documentation Question

    Hello out there! I'm trying to find information on proper documentation for past, family, and social history. I know that "unremarkable" and "reviewed" are unacceptable, but I've run into this one lately: "No significant family history pertinent to this hospitalization." To me, that seems like...
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    Wiki Debate

    Question - There has been some debate on two items relating to E/M coding and I would love feedback that may help me to not only educate myself but my physicians and colleagues... 1. Medical Decision Making - we utilize the 1999 Table of Risk - but there is some debate in determining what...