Reader Questions: Documenting PFSH Is Not as Hard as You Think

Question: Many times our physicians will flip back in an established patient's chart and quickly review the original patient intake forms that include the patient's past, family, and social history (PFSH). The physician may ask questions such as "Has anything changed since you completed this form?" or "Are you still married?" or "Do you still smoke?" and make notations accordingly. Is there any way for us to count this time toward a comprehensive history?

Idaho Subscriber

Answer: Yes, you can use this information to help support a comprehensive history, but certain documentation is essential.
 
A review of PFSH as you described can qualify as a complete PFSH - a component necessary to justify a comprehensive history, which in turn may contribute to a higher-level E/M service. But you cannot count this information if the physician doesn't make a summary notation of the PFSH review and reference the exact location (patient intake form) and date (when the patient completed the form) of the original patient PFSH.
 
Help your physician: Make documenting a review of PFSH easy for your physician by including two boxes on the medical chart form for your physician to check if applicable. Use these guidelines to help set up your form correctly: