If the patient has completed the questionaire and the physician has initialed/signed and dated, and also referenced this document in his clinic notes, then you give credit for whatever the patient completed on the PMFSH and ROS.
Ideally the physician will also make some statement as to pertinent positives or negatives, but even if s/he doesn't do this, you can still give credit for all that the patient completed on the form. (I've seen forms that don't have 14 systems on them. I've seen forms with 14 systems, but the patient only checks the few positives, or what the patient thinks is pertinent. I've seen forms with no social history questions. ...)
F Tessa Bartels, CPC, CPC-E/M
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