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ROS and PFSH by ancillary staff - require a statement

  1. #1
    Default ROS and PFSH by ancillary staff - require a statement
    Medical Coding Books
    It is my understanding that if ancillary staff gather the ROS and past medical, family, and surgical history, or if this information was carried forward from a previous visit in an electronic medical system, the provider must make a notation that they reviewed and/or updated this information. A provider at my clinic is stating that by signing the note, she is confirming that all of the information contained within the note has been reviewed and verified by her. Is it true that a signature is all that is required? Or does an auditor require a statement that the provider reviewed the information that was either pulled forward from a previous visit or gathered at that visit by the medical assistant?
    Thank you very much for any help with this

  2. Thumbs up
    Here is some information that I have from AAFP. It addresses previous PFSH/ROS data and also ROS and PFSH documented by ancillary staff separately, along with some other helpful information regarding E/M documentation.

    "The Review of Systems and the Past, Family and/or Social History may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, the physician must add a notation supplementing or confirming the information recorded by others."

    "An ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded 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."

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