Wiki previous visits

[krssy70]

Hello all,

I have a physician that is dictating his note for a follow-up visit in his office. He states that past medical history and ROS is unchanged from previous visit note, (and states the date of service). Does that mean that I can utilizie the previous note for the components of the HPI in this current note?

any help on this, Thanks
Kristen

 

[colleenwade]

No. Only the ROS and PFSH may be taken from another source that is identified by name and date. The HPI must be independently documented for each and every visit.

 

[krssy70]

I'm sorry, that is what I was saying. The doctor stated that the ROS and PFSHx was previously documented in the previous visit note. My question was can I use that previous note (because the doctor gave me the date of the previous note) for the current note, because he said that it was unchanged from the previous visit(and he gave me the exact date). HOpe that makes more sense. Sorry

 

[RebeccaWoodward*]

I'm sorry, that is what I was saying. The doctor stated that the ROS and PFSHx was previously documented in the previous visit note. My question was can I use that previous note (because the doctor gave me the date of the previous note) for the current note, because he said that it was unchanged from the previous visit(and he gave me the exact date). HOpe that makes more sense. Sorry

Per the documentation guidelines:

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a
physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and

• noting the date and location of the earlier ROS and/or PFSH.