E/M Weekly Tip: Review of Systems; and Past, Family and Social History - Obtained During an Earlier Encounter

A review of systems (ROS) and/or a past, family and social history (PFSH) obtained during an earlier encounter do not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• Describing any new ROS and/or PFSH information or noting there has been no change in the information
• Noting the date and location of the earlier ROS and/or PFSH