LETTERS

Documenting history


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Fam Pract Manag. 2004 Jan;11(1):17.

To the Editor:

In “Two Tried-and-True Tools for E/M Documentation” [October 2003, page 51], the progress note uses a check box to indicate no change in the past, family and social history (PFSH). While this is perfectly appropriate, the Documentation Guidelines for Evaluation & Management Services indicate that the date of the last review of the PFSH must be indicated as well. It states, “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. ... 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.”

Editor’s note:

We’ve made the change you suggested in the online version of our form. Thank you for helping us to improve it.

 

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