Many providers under document history because they know the patients and they have the rest of the chart at their disposal. It seems repetitive to them to re-document what is in the previous note(s).
I teach a lot of providers, I always stress the importance of their documentation standing alone if they are not appropriately referencing other documentation. Many are taken aback by this concept and I have to explain that an external auditor, such as CMS, will not have your chart and they don't know your patients. All they have is this one dates note. Once they understand why something is needed they are generally more aware of it and the documentation should improve. Of course old habits are hard to break so back sliding is normal and to be expected. They just need continual feedback, positive and negative.
The other common issue with missing information is that it was negative. The provider asked but got a negative response so they don't remember to state that. I also stress pertinent negatives get the same credit as positives.
As for PFSH specifically, I see more issues on the inpatient initial visit than new patient visits. Generally new patient visits are accompanied by an intake form that captures that information, so the providers just need to get in the habit of referencing that form when they review it if they don't want to re-document the info. On the inpatient side I see many cases where family history truly isn't pertinent or relevant, but to bill a 2 or 3 you have to have it. A lot of providers don't realize the only difference between the 2 and 3 is the MDM and I see many initials drop to 1 or subsequent care due to missing family history or ROS.
Just my experience for what its worth,
Laura, CPC, CPMA, CEMC