When a provider only documents in the PFSH and ROS that "Health Questionnaire I reviewed in detail with the patient." is this adequate documentation, even if this questionnaire, filled out by pt, is scanned elsewhere in the chart? Provider has put this for a 99244 and has left findings/results space blank for the PFSH and ROS. Thanks!
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Health questionnaire
- Thread starter mg65
- Start date
Pam Warren
True Blue
I would recommend that he discuss any pertinent positives or negatives. Certainly with a chief complaint, there would be a positive system review?Without that documented, you don't have any ROS, because the comment that he simply reviewed a scanned document does not tell you anything.
When was the patient questionnaire done? That information is necessary, because the patient could have filled it out six weeks ago, and the information might have changed. If so the provider needs to mention that. Same with the PFSH....is this a new patient? If so,you can't reference an 'old' PFSH. You have to have a starting point, particularly as it pertains to the chief compliaint.
Personally, I dislike scanned records in an EHR...you lose the reporting capability when you don't enter data into the pre-designed fields, and you also have to be careful about documenting updates, changes, deletions and dates when you reference a scanned document. Encourage your physician to use the EHR as it was designed and fill in the ROS and PFSH.
When was the patient questionnaire done? That information is necessary, because the patient could have filled it out six weeks ago, and the information might have changed. If so the provider needs to mention that. Same with the PFSH....is this a new patient? If so,you can't reference an 'old' PFSH. You have to have a starting point, particularly as it pertains to the chief compliaint.
Personally, I dislike scanned records in an EHR...you lose the reporting capability when you don't enter data into the pre-designed fields, and you also have to be careful about documenting updates, changes, deletions and dates when you reference a scanned document. Encourage your physician to use the EHR as it was designed and fill in the ROS and PFSH.