Where in the medical record can ancillary personnel document patient information?
The Review of System (ROS) and / or Past Family Social History (PFSH) may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. Additional documentation requirements are located in the 1995 and 1997 Evaluation and Management Services Guidelines on the Centers for Medicare and Medicaid Services website at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.
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