What must be documented when referencing past information for the Review of Systems (ROS) and Past Family Social History (PFSH)?

When documenting references to past information for the Review of Systems (ROS) and Past Family Social History (PFSH), it is crucial that the doctor reviews and updates previous information. This means that in the medical record, there should be a clear indication that the physician has actively assessed the relevant historical data and made any necessary updates based on new patient information or changes in the patient's condition.

Updating previous information is important for several reasons. It ensures that the medical record reflects the most current and accurate information, which is vital for ongoing patient care. It also demonstrates that the physician is engaging in thorough and comprehensive evaluation practices, fulfilling documentation requirements that enhance patient safety and improve outcomes. Furthermore, this practice can support proper coding and billing, as it provides clarity about the level of service provided during the visit.

The emphasis on updating rather than merely verifying or deleting information indicates the importance of building a comprehensive and accurate patient history that informs clinical decision-making.