Wiki Drs under document history

[GAcoder]

Why do doctors so often under document history in E & M? Don't they realize it makes big difference in the level of service?
I most often find the PSFH missing. Especially on new patients.

 

[MarcusM]

Having worked for multiple doctors in multiple specialties, PSFH is "BORING" and seldom has clinical relevance to the issue at hand. I as a patient am also not concerned with relating PSFH to medical providers for the same reason. My prior history of a broken right thumb and laceration with surgical intervention has no clinical relevance to my left knee pain due to a slip and fall on wet pavement. BUT, our job is to educate the providers to document, document and then document some more.

 

[GAcoder]

If you have systemic disease such as diabetes it's important to know. It impacts your care.

 

[LLovett]

Many providers under document history because they know the patients and they have the rest of the chart at their disposal. It seems repetitive to them to re-document what is in the previous note(s).

I teach a lot of providers, I always stress the importance of their documentation standing alone if they are not appropriately referencing other documentation. Many are taken aback by this concept and I have to explain that an external auditor, such as CMS, will not have your chart and they don't know your patients. All they have is this one dates note. Once they understand why something is needed they are generally more aware of it and the documentation should improve. Of course old habits are hard to break so back sliding is normal and to be expected. They just need continual feedback, positive and negative.

The other common issue with missing information is that it was negative. The provider asked but got a negative response so they don't remember to state that. I also stress pertinent negatives get the same credit as positives.

As for PFSH specifically, I see more issues on the inpatient initial visit than new patient visits. Generally new patient visits are accompanied by an intake form that captures that information, so the providers just need to get in the habit of referencing that form when they review it if they don't want to re-document the info. On the inpatient side I see many cases where family history truly isn't pertinent or relevant, but to bill a 2 or 3 you have to have it. A lot of providers don't realize the only difference between the 2 and 3 is the MDM and I see many initials drop to 1 or subsequent care due to missing family history or ROS.

Just my experience for what its worth,

Laura, CPC, CPMA, CEMC

 

[GAcoder]

Many physicians will check reviewed but not have a date reviewed, so we can't count it. Sometimes it's just simple things the physician doesn't document like that which lowers level. Thanks Laura

 

[rlmiller]

I also have a question how long is the history valid, 6 months, one year? I tried to find a reference for this but could not. Our physicians are added dates reviewed which is great but how long is that good for?
Thanks, Robin

 

[MFMcoder]

RE: drs under document history

I've been told that if the condition is still being treated or monitored, it is current & not "history of". I would also like to have a reference to support that statement. Not because I disagree or am skeptic. I just need support when asked for the information's source.

I also need a source on what determines the relevance of "family" in family history. It is one thing if the "history" part is not really relevant to the chief complaint, signs, symptoms etc. But also if the "family" member for a newborn is it's paternal grandma's first cousin and no other relatives. Is that a reach? Especially when that is the reason given by the doctor for a specialist to see the newborn.

Any advice on that?