# Past, Family, and/or Social History (PFSH)



## KoBee (Dec 28, 2018)

Have some confusion in understanding the proper way to document a PFSH. I have a provider who only documents " Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate " in all his visits

*Per E/M guidelines:* You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter 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.
You may document the review and update by:
• Describing any new ROS and/or PFSH information or noting there is no change
in the information
*• Noting the date and location of the earlier ROS and/or PFSH*


by him signing and dating below, is this sufficient to account for a PFSH????


This is an example of the providers documentation:


*Chief Complaint
Patient presents with*
•	Hypertension

*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
*Review of Systems *
Neurological: Positive for headaches. 
*
*
*
*Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.*
*
*

*Objective:*
Physical Exam 
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. 
Cardiovascular: Normal rate.  
Neurological: He is alert and oriented to person, place, and time. 
*
*
*
*Assessment:*
*
1.	HTN, goal below 140/90 	losartan (COZAAR) 50 MG tablet
*	DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
 RTc in 1 week for bp control.




Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM


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## kdlberg (Jan 11, 2019)

The date of the prior encounter needs to be included in that statement, such as "Patient's medications, allergies, past medical, surgical, social and family histories from 12/15/18 were reviewed."

Also, if anything was updated, what was it? Assume the reviewer won't have previous encounters for the same patient to refer back to; they're not going to be able to compare those elements between the two encounters and see what the changes were. They don't need to write a novel. "Mother recently dx'ed with breast cancer," "had lasik surgery since last visit." If there are no changes, it's acceptable to say "no changes."


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