Wiki PFSh

[solocoder]

One of our doctors always states in his note: I have reviewed in detail in the patient's electronic medical record this date the past medical history, present medications, allergies, past surgical history, family history and social history.
If I am understanding correctly, I can count that? But how much credit do I give it? How do I know what lever of PFSH to call that?

 

[ajs]

One of our doctors always states in his note: I have reviewed in detail in the patient's electronic medical record this date the past medical history, present medications, allergies, past surgical history, family history and social history.
If I am understanding correctly, I can count that? But how much credit do I give it? How do I know what lever of PFSH to call that?

This information is from an article in an online Physician Practice publication. I think it states pretty well what the requirements are for recording PFSH in an EMR.

" A 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. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. 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 ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."

 

[solocoder]

Thank you so much for your reply. Still not sure what kind of credit to give for a "reviewed" PFSH with no updates. Any thoughts?

 

[FTessaBartels]

It will depend on what is documented in the chart

Thank you so much for your reply. Still not sure what kind of credit to give for a "reviewed" PFSH with no updates. Any thoughts?

That will depend on what is actually documented in the chart. I had one doctor who always relied on his resident to document the ROS and PFSH ... his note always said, "have reviewed resident H&P of mm/dd/yy." So I'd go look at the H&P ... and the doctor got credit for what the resident documented ... sometimes that was nothing!

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[ajs]

Thank you so much for your reply. Still not sure what kind of credit to give for a "reviewed" PFSH with no updates. Any thoughts?

Depends on what was "reviewed". Have to go back and look at the documentation the provider is referencing they "reviewed" and give credit for what was documented at that time.