Wiki PFSH documented as "non-contributory" - do you give credit?

[tsmith19]

I have a provider who documented a patient's family history as "non-contributory". To me this statement is too vague. It isn't explicit what the provider means by that statement. This is a new patient visit, so counting (or not counting) this documentation will can make the difference between a detailed or comprehensive history. Are there any guidelines regarding this statement and whether it can be used to give credit for family history?

 

[tahoffman01]

A handout from CMS/Trailblazers states that you can not use the term "non-contributory". To be able to give credit it must have at least one documented aspect or say that it was reviewed and unchanged or something to that sort.

 

[rthames052006]

I have a provider who documented a patient's family history as "non-contributory". To me this statement is too vague. It isn't explicit what the provider means by that statement. This is a new patient visit, so counting (or not counting) this documentation will can make the difference between a detailed or comprehensive history. Are there any guidelines regarding this statement and whether it can be used to give credit for family history?

Hello...

In the scenario you set forth I would not give credit for that statement. My reasoning being that this is a "new" pt to the practice you would want some type of family history, it could be relevant down the road.

If this were a visit for a "simple" visit like say sinusitis, something minor I would say it could be non-contributory to the presenting problem.

I get my providers into the habit of getting "some kind of fm hx".

Just my opinion