Wiki PFSH statements

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lhoot

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This might seem like a silly question, but I’m hoping someone might humor me anyways. I have seen records with a statement such as, “The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.” The record doesn’t list any of these areas separately or have additional documentation about these items. Would there be any credit given for PFSH for this?

Thanks,
Laura
 
Per the 1995 E&M guidelines:

"ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.... The review and update may be documented by:
  • describing any new ROS and/or PFSH information or noting there has been no change in the information; and
  • noting the date and location of the earlier ROS and/or PFSH."
The statement you quote does not meet the requirements in the two bullet points above in that is does not indicate whether or not the were any changes or updates to the PFSH and does not reference the location of the prior information, so in my opinion, most auditors would likely not give credit for the PFSH because of this.

Statements in a record such as 'x was done as appropriate' or 'if the patient had x, then y was done' are templates that do not record any patient-specific information and these fall under the category of cloned records, which are generally not allowable.
 
Last edited:
lhoot said:
Thank you , Thomas.
You gave me validation that I wasn't missing something.
Laura
Click to expand...
Update due to Electronic Medical Records. I'm someone who has been in the medical field for decades. I never thought that "charts" would be replaced, but they have been. However it has caused more problems than it has solved in my opinion. One of the things that you routinely see now, that you never saw when charts were used, is "Comprehensive" history on virtually every patient regardless if they are being seen for a new problem, or a simple follow up. In the days of chars the medical staff documented pretty much only what they needed to after all the doctor was going to have to hand write out the office note. So basically the three key components of an office visit were congruent and matched what the patient was being seen for. With EMR the clinical staff treat all the fields as something that must be filled out. So every visit has four HPI elements. I even had one provider type in "N/A' in four of the HPI fields, and the computer dutifully gave him credit for four HPI elements. At every visit the PFSH is always reviewed and all fourteen ROS elements are gone over - on every single visit. So every single patient has a "Comprehensive' History documented. Now let me ask you a question. Does every single patient NEED a comprehensive history performed? Of course not. But due to EMR they are even though it's not medically necessary. Just from your question and the way it's asked I'll bet that this is happening where you are too. This is one of the reasons that CMS is changing the guidelines for E/M to be focused on "Medical Decision Making" rather than amount of documentation provided which CMS has always argued should not be a factor in choosing an E/M level.
 
Orthocoderpgu said:
Update due to Electronic Medical Records. I'm someone who has been in the medical field for decades. I never thought that "charts" would be replaced, but they have been. However it has caused more problems than it has solved in my opinion. One of the things that you routinely see now, that you never saw when charts were used, is "Comprehensive" history on virtually every patient regardless if they are being seen for a new problem, or a simple follow up. In the days of chars the medical staff documented pretty much only what they needed to after all the doctor was going to have to hand write out the office note. So basically the three key components of an office visit were congruent and matched what the patient was being seen for. With EMR the clinical staff treat all the fields as something that must be filled out. So every visit has four HPI elements. I even had one provider type in "N/A' in four of the HPI fields, and the computer dutifully gave him credit for four HPI elements. At every visit the PFSH is always reviewed and all fourteen ROS elements are gone over - on every single visit. So every single patient has a "Comprehensive' History documented. Now let me ask you a question. Does every single patient NEED a comprehensive history performed? Of course not. But due to EMR they are even though it's not medically necessary. Just from your question and the way it's asked I'll bet that this is happening where you are too. This is one of the reasons that CMS is changing the guidelines for E/M to be focused on "Medical Decision Making" rather than amount of documentation provided which CMS has always argued should not be a factor in choosing an E/M level.
Click to expand...

I agree with everything you said. I also believe that it's not just the computers that have a broad interpretation of valid responses. I have know some humans to give their approval on some of these same types of entries.

Thank you for your very relevant observation.
Laura
 
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