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PFSH and EXAM

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I have a new physician and he states for the PFSH "A complete review of the patients medical record was performed. The patients past medical, surgical, social, and family histories are reviewed and confirmed with the patient and are unchanged from previous notes." (Do you count this as complete PFSH)? Also on the Exam he states "Examination findings in this patient are completely unchanged from my previous note." How would you count that as an exam?

Any help would be appreciated so I can explain to the provider.
 

rthames052006

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really

I have a new physician and he states for the PFSH "A complete review of the patients medical record was performed. The patients past medical, surgical, social, and family histories are reviewed and confirmed with the patient and are unchanged from previous notes." (Do you count this as complete PFSH)? Also on the Exam he states "Examination findings in this patient are completely unchanged from my previous note." How would you count that as an exam?

Any help would be appreciated so I can explain to the provider.
Hi Brenda,

For the PFSH if the provider states "the patients past, medical, surgical, social and family history was reviewed and confirmed with the patient and are unchanged from the previous notes" he must state where this previous note is located and the date of it, so that if audited you can provide this information ( also when you audit) this note you should be looking for that specific date of service and make sure these items are "documented".

As for the exam - you cannot use that the provider must document an exam for this visit. I'd like to know what the patients chief complaint / reason for this visit is. If this is an established pt you only need 2 of the 3 key components ( just keep that in mind).
 
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