Wiki EMR/EHR documentation

[Greenpiper]

Our providers have started using canned text for PFSH. We are not sure why but are questioning the validity of this text.

"Past medical, surgical, and family histories reviewed for relevance to current acute and chronic problems."

We clinic coders do not feel this is sufficient documentation. Any thoughts on this?

For example if patient is in for colon screening with no personal history of issues and the above statement is all we get, we cannot determine if there is a family history and may receive a denial.

Thank you
Corenna CPC

 

[Chelle-Lynn]

Since PFSH tends to remain fairly steady (for the most part) it is acceptable for a provider to use a statement of "Past, Family, and Social history was reviewed for relevance to current acute and chronic problems." However, the provider needs to note any changes or that there are no changes to the information. They also need to note the date and location of the earlier PFSH.

Per CMS:

You do not need to re-record a PFSH obtained during an earlierencounter if there is evidence that the physician reviewed and updated the previousinformation. This may occur when a physician updates his or her own record or in aninstitutional 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 changein the information
• Noting the date and location of the earlier ROS and/or PFSH