Wiki History unchanged ....

[renifejn]

If a physician states family hx unchanged from previous visit---is this acceptable? I know that it must state "family hx unchanged since {insert date} but, ..........???????


...darn doctors for trying to take short cuts all the time


thanks

 

[RebeccaWoodward*]

You are on the right path...If my physicians choose to document this way, then I always refer to this section of the "DG's". I've taken a few, scrubbed, examples to E/M workshops and the Medicare guru's state we are in compliance.

DG: 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.