Recording family hx from form to EMR

cindyhowerton

Networker
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30
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0
Our practice has paper forms our patients fill out for PFSH. The Family History portion has an option of "No Family History" so they do not have to check the 'No' box on each of the items listed below it. If there is any history, the patient checks the 'Yes' box next to the specific positive item and then 'No' to the negative ones.

My question is: When we transfer the 'No Family History' item into our EMR, do we have to mark the 'No' next to each specific item on our template? Or is it enough to say "Patient reports no family history?"

We are in the process of revising our templates and some of our providers indicate they were taught that in this scenario each item must be marked, but it does involve a lot of 'clicking' by the staff...

Thank you for your help.
 

jk2003

Networker
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Location
Whitestone, NY
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According to CMS guidelines, you need to make only one comment for each category.
I.E.: Past medical: No known allergies/sureries; Family: Mother has HTN/diabetic; Social: Doesn’t smoke/drink. Physicians have gotten in the habit of referring to one of these elements as “non-contributory.” But it is frowned upon. A better option would be to say, “Family history reviewed and is non-contributory to patient’s illness.”
 
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