Wiki Opinion on PFSH

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NESmith

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Good Afternoon,

If a provider documents in a patient's record, I have reviewed and confirmed Family History, Medical History, and Social History with the patient and listed it above and below unless there was no contributory information.
Would you except this as elements for the PFSH and give the doctor credit?
Thank You
 
Assuming your provider is actually documenting 'listed it above and below unless there was no contributory information' and you are not just paraphrasing here - I would not accept this as PFSH if I was auditing. The recent guidance given by CMS regarding electronic records, cloning and copy/paste has been very clear that medical records should contain information that is personalized to the patient being treated and that generic statements that are repeated in all notes which do not add any patient-specific information are not acceptable.
 
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There have been a lot of publications from different organizations that discuss this, but here is a good starting point:

https://www.cms.gov/Medicare-Medica...ownloads/docmatters-ehr-providerfactsheet.pdf

On page two, under 'Words of Caution', they discuss cloning and state that "The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable."

There are also a number of references at the end that will take you to other sources. The OIG, in particular, has mentioned this almost every year in their annual reports and has recommended that CMS develop and publish better guidelines for proper EMR use in order to prevent potential fraud, and also that provider organizations create their own internal EMR use guidelines. AHIMA and JCAHO I believe have also published some recommendations and sample guidelines for providers in the regard.
 
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