Documenting history


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.



Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.


Copyright © 2004 by the American Academy of Family Physicians.
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