Wiki PFSH should it be in the note or just in EMR

[Donna Jean]

Should it be documented in the note or just in the patients EMR? My providers think that if its documented in an EMR tab that they do not need to document in the note.....I say if new patient needs a complete PFSH and if established patient then at least 1 of the three. Or they can refer to a prior PFSH and state it was reviewed from such and such date and note changes or whatever changes need to be documented. Thanks

 

[jocarter]

Pfsh

The Healthsystem I work for is very conservative. We are on the EPIC system and have decided that it is not sufficient to just checked off a box to state they reviewed it or put a blanket statement in the notes that the information was reviewed. Instead we require our providers pull the information they reviewed into their documentation.

It would be interesting to see what other offices do on this.

Thanks,
Jolene Carter, CPC, CPMA

 

[mhstrauss]

I agree that just having it in the History tab of the EMR is not sufficient. Our office uses GE Centricity; when the "reviewed" box is checked for any of the history elements (past medical, surgical, family, and social are all separate), the EMR automatically pulls in the info from the last visit, along with the date that it was documented, and if any changes are necessary, they can be made at that point.

Just to point out, if this isn't included in the E/M note, and the note is sent out for audit or claim purposes, whoever is sending the record won't know to send the History tab also, and whoever is reviewing the note won't know that it was really reviewed, just not documented in the note.

HTH some!