Wiki PMFSH statement

lnaschke

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I have a running disagreement about the PMFSH statement in our EMR. In this section of the note it states "PMHX was reviewed and/or modified." Nothing else. When I look at the area in the eMR where this resides, there are no indications that the PMFSH was looked at or modified in any way. I believe that this represents insufficient documentation of the PMFSH in the note, but the providers disagree.

Does anyone else have this issue with their EMR?
 
You are correct it is not enough and tells us absolutely nothing

See below

Family History (FH): A review of medical events in the patient?s family which may include information about:

The health status or cause of death of parents, siblings and children
Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
Diseases of family members which may be hereditary or place the patient at risk

Social History (SH): An age appropriate review of the patient?s past and current activities which may include significant information about:

Marital status and/or living arrangements
Current employment
Occupational history
Use of drugs, alcohol or tobacco
Level of education
Sexual history
Other relevant social factors

There are two levels of PFSH :

Pertinent PFSH: At least ONE specific item from ANY of the three components of PFSH must be documented.
Complete PFSH: A review of two or all three of the PFSH components are required depending on the category of E/M service

At least ONE item from TWO out of three PFSH components must be documented for a Complete PFSH for:

1) Established Office Patient
2) ER visits
3) Subsequent Nursing Facility Care
4) Established Patient Domiciliary Care
5) Established Patient Home Care

At least ONE specific item from THREE of the three components of PFSH must be documented for a Complete PFSH for:

1) New Office Patient
2) Hospital Observation Services
3) Hospital H&P
4) Consultations
5) Comprehensive Nursing Facility Assessments
6) New Patient Domiciliary Care
6) New Patient Home Care


You docs are welcome to pull forward the patient's PMFSH into the current encounter and then update it as needed. Certain truths will never change, cause of death of family members for example.

See the reference:
http://emuniversity.com/PFSH.html
 
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