Wiki Past, Family, and/or Social History (PFSH)

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KoBee

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Just want to make sure I am understanding the guideline correctly because I am getting many different responses.

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


I have provider who just documents " Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate." on established patients.


Is this sufficient to count or should the provider be putting an ACTUAL DATE from previous encounter ??


Help please??
 
First, YES, there most definitely needs to be a date for the previous encounter. 99% of the time, a reviewer is not going to have access to the schedule or the patient's previous encounters.

Second, I do not believe the documentation is sufficient. The directive from CMS is: "Describing any new ROS and/or PFSH information or noting there is no change" (Italics for emphasis)

So the provider should say exactly what, if anything, is new and include a statement and say everything else was reviewed and is the same. "Reviewed PFSH and ROS from 12/1. Ear pain has resolved, no other changes." Or "Reviewed PFSH and ROS from 12/1, no changes."
 
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