For an established patient the physician does NOT need to re-record a PFSH if there is an earlier chart having documented this part for the History component. It is acceptable to review the previous PFSH and note if there are any changes. Keep in mind when using this shortcut, you must note the date and location of the earlier PFSH and comment on any changes in the information since the original PFSH was recorded.
This shortcut applies ONLY to an established patient.
As an example, you can state in your chart the following:
“A comprehensive PFSH from previous encounter was reviewed with the patient. Nothing changed since the chart dated 09/15/2016”