Wiki H&P Family History

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Svirgilio

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Our providers see patients in nursing homes and assisted living facilities. I noticed some of our Doctors are documenting under Family History "Not on file in chart" I do not feel comfortable giving them credit for this. Please let me know how you guys feel about this. I cannot tell from this documentation if the patient just does not have a family history which could be true or it is just missing.
 
I see no credit for this statement. This is not the same as saying there is no significant family history to report . It says there was nothing in the chart and we did not ask. So no, family history cannot be counted as reviewed.
 
I have seen that phrase too, and I didn't give credit. I was told that some EMR's will automatically insert that phrase in an attempt to prompt the provider to document some family history. Stating that there is nothing on file is not enough to get credit for documenting family history.
 
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