Have some confusion in understanding the proper way to document a PFSH. I have a provider who only documents " Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate " in all his visits
Per E/M guidelines: You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter 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.
You may document the review and update by:
• Describing any new ROS and/or PFSH information or noting there is no change
in the information
• Noting the date and location of the earlier ROS and/or PFSH
by him signing and dating below, is this sufficient to account for a PFSH????
This is an example of the providers documentation:
Chief Complaint
Patient presents with
• Hypertension
*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
Review of Systems
Neurological: Positive for headaches.
*
*
*
Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
*
*
Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.
Cardiovascular: Normal rate.
Neurological: He is alert and oriented to person, place, and time.
*
*
*
Assessment:
*
1. HTN, goal below 140/90 losartan (COZAAR) 50 MG tablet
* DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
RTc in 1 week for bp control.
Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM
Per E/M guidelines: You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter 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.
You may document the review and update by:
• Describing any new ROS and/or PFSH information or noting there is no change
in the information
• Noting the date and location of the earlier ROS and/or PFSH
by him signing and dating below, is this sufficient to account for a PFSH????
This is an example of the providers documentation:
Chief Complaint
Patient presents with
• Hypertension
*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
Review of Systems
Neurological: Positive for headaches.
*
*
*
Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
*
*
Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.
Cardiovascular: Normal rate.
Neurological: He is alert and oriented to person, place, and time.
*
*
*
Assessment:
*
1. HTN, goal below 140/90 losartan (COZAAR) 50 MG tablet
* DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
RTc in 1 week for bp control.
Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM