Wiki PFSH Documentation

[lnaschke]

I have an Urgent Care Clinic that consistently documents the PSFH asf follows:

Past Medical History: No significant past Medical History. Has no prior surgeries.
Family History: No significant family history
Social History: Patient is employed. Patient is a current everyday smoker. Unclear when patient started smoking. Patient is sign. Patient live with family. Social drinker. No drug use.

My question is this...would you count all three for a comprehensive PSFH, or, would you count just the Medical and Social Histories. I lean toward the latter, but the providers believe that counting all three is appropriate.

 

[vpat28]

The documentation only satisfy 2 element of PFSH. Past and Social history.

 

[thomas7331]

I agree. I think it's the kind of thing an auditor might allow if it happened on the occasional note and everything else looked good, but if it's used consistently used to bump up the E&M levels, it could put you at risk. It's a simple fix if the providers can just change the wording an say what exactly was not significant.

 

[bedforak1]

I agree. Since it's documented consistently, you are at risk. PFSH is one of the first things auditors look at.