1073358
Expert
The guidelines state for ROS/PFSH that:
❖ A ROS and/or a PFSH obtained during an earlier encounter does not need to be re- recorded if
there is evidence that the physician reviewed and updated the previous information. This may occur
when a physician updates his or her own record or in an institutional setting or group practice
where many physicians use a common record. The review and update may be documented by:
? Describing any new ROS and/or PFSH information or noting there has been no change in the
information; and
? Noting the date and location of the earlier ROS and/or PFSH.
❖ The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To
document that the physician reviewed the information, there must be
a notation supplementing or confirming the information recorded by others.
An office member and myself are not in agreement over this requirement. I feel that the dr needs to type in something in the EHR stating that he agrees with whatever nurse wrote down, or that he reviewed it, etc.
The other member feels that the signature at end of the dictation is proof enough since they have to scroll through the note to get to the place where they actually sign their documentation to make it complete in the record.
I need even more clear info than that of the guidelilnes above. Help please.
❖ A ROS and/or a PFSH obtained during an earlier encounter does not need to be re- recorded if
there is evidence that the physician reviewed and updated the previous information. This may occur
when a physician updates his or her own record or in an institutional setting or group practice
where many physicians use a common record. The review and update may be documented by:
? Describing any new ROS and/or PFSH information or noting there has been no change in the
information; and
? Noting the date and location of the earlier ROS and/or PFSH.
❖ The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To
document that the physician reviewed the information, there must be
a notation supplementing or confirming the information recorded by others.
An office member and myself are not in agreement over this requirement. I feel that the dr needs to type in something in the EHR stating that he agrees with whatever nurse wrote down, or that he reviewed it, etc.
The other member feels that the signature at end of the dictation is proof enough since they have to scroll through the note to get to the place where they actually sign their documentation to make it complete in the record.
I need even more clear info than that of the guidelilnes above. Help please.