Forum - Questions & Answers

Sep 10th, 2010 - blm321 27 

Comprehensive or Detailed History

I have a physician that dictates every requirement of a Comprehensive History, except he puts "Social History Reviewed". He does not go into social history. I am always bumping him down to a Detailed History, because the guidelines state "complete past, family AND social history". Am I doing this correct?

Sep 11th, 2010 -

I say---

it counts. It would be better to indicate the date of the last one or add "no change" to the "reviewed" but I'm gonna side with the doctor here.

What say you Editor, coding audit queen?

Sep 12th, 2010 - Codapedia Editor 1,399 

Social history reviewed

I usually count it. I prefer if it says, "SH reviewed, no changes required.) I don't insist on location if it is the patient's current chart. (My opinion.) If it is a history from another location, like an admission, then you need the location for sure.

Here is the exact wording from the guidelines:

!DG: 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.



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