How old can you use a history on a pt.

heidi3

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I have a md that uses old H&P's on follow up visit.
how far back can you go.
thanks
 
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Milwaukee WI
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Depends on documentation

As usual, everything depends on documentation.

As long as the MD has indicated the original date of the information, the current date of review, and any changes (or lack thereof), it meets the standard for reviewing the history.

Speaking for myself ONLY ... My family/past medical history / ROS remained the same for over 20 years! No body had any surgeries, major illnesses, symptoms ... ridiculously healthy people. All my doctor needed to ask was if there were any changes from the history in the chart. (He DID have me fill out a new form every 2 or 3 years, but even if he hadn't, the history would not have changed.)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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