E/M Weekly Tip: Review of Old Records and Past, Family and Social History (PFSH) from Others

Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed" or "Additional history obtained from family" without detailing/describing the actual information received is insufficient.