Hello out there!
I'm trying to find information on proper documentation for past, family, and social history. I know that "unremarkable" and "reviewed" are unacceptable, but I've run into this one lately: "No significant family history pertinent to this hospitalization." To me, that seems like it's saying the same thing as "unremarkable," but I want to be sure to give the provider credit if it turns out that that dictation is allowable.
Also, what if the provider refers to another provider's documentation for the PFSH? For example, if a neurologist does a consult but just says to refer to the hospitalist's H&P for the PFSH, is that acceptable? I would think it would be okay if the neurologist provided some sort of update or documented that the PFSH is unchanged from when the hospitalist gathered the history -- However, in my case, the neurologist simply says to refer to the hospitalist's H&P for the PFSH. To me, that doesn't seem quite right.
I would be grateful for any information and/or insight on this.
Thanks much.
I'm trying to find information on proper documentation for past, family, and social history. I know that "unremarkable" and "reviewed" are unacceptable, but I've run into this one lately: "No significant family history pertinent to this hospitalization." To me, that seems like it's saying the same thing as "unremarkable," but I want to be sure to give the provider credit if it turns out that that dictation is allowable.
Also, what if the provider refers to another provider's documentation for the PFSH? For example, if a neurologist does a consult but just says to refer to the hospitalist's H&P for the PFSH, is that acceptable? I would think it would be okay if the neurologist provided some sort of update or documented that the PFSH is unchanged from when the hospitalist gathered the history -- However, in my case, the neurologist simply says to refer to the hospitalist's H&P for the PFSH. To me, that doesn't seem quite right.
I would be grateful for any information and/or insight on this.
Thanks much.