Question: Can I count past, family, social history (PFSH) items that I record using a sheet?
Georgia Subscriber
Answer: Yes. You can use a sheet to record PFSH. Properly document that you updated the sheet by noting “Refer back to _________ for pertinent information” in your current encounter. List any changes from the initial recoding to the current visit. When referencing information in other documents, make sure the referenced information is present. An insurer/auditor may also request that the information be copied/included with the progress note.