Question: Can I count past, family, social history (PFSH) items that I record using a sheet? Georgia Subscriber
Answer: Yes. You can use a sheet to record PFSH. Properly document that you updated the sheet by noting -Refer back to _________ for pertinent information- in your current encounter. List any changes from the initial recoding to the current visit. When referencing information in other documents, make sure the referenced information is present. An insurer/auditor may also request that the information be copied/included with the progress note.