FAQ #10
       
When I am seeing a patient for a follow-up visit, can I refer to a previous past medical, family and social history and ROS or do I have to re-write them for each visit?

Answer: It's probably okay to refer to the documentation contained in an earlier note. The E/M guidelines state:

"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."

So, you have to say something like, "The complete PFSH and ROS recorded during an earlier encounter were reviewed with the patient. No changes are noted today. For details, please refer to my ealier note located in this chart, dated September 15, 2008."

Despite the fact that this shortcut is printed in the E/M guidelines, we are sorry to say that some Medicare carriers may not recognize it so you should check with your individual carrier before using it in your notest.