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Notes on the Documentation of History

Notes on the Documentation of History

You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI.

You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter 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. You may document the review and update by: Describing any new ROS and/or PFSH information or noting there is no change in the information or noting the date and location of the earlier ROS and/or PFSH.

  • Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information.
  • If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.