# Social History - greatly appreciated



## codingdemon62 (Mar 11, 2008)

I have a patient that was seen in the ED and in the HPI the Dr states "caregiver states  blah blah blah,,,  My question is would you consider that the pt's caregiver is enough to be considered for the Social History

All replies would be greatly appreciated.


----------



## member7 (Mar 11, 2008)

I say yes, but would venture that the physician would need to be careful in who he shared personal information with about the patient.


----------



## jbagsic (Mar 12, 2008)

i would credit it for "decision to obtain history from someone other than the patient" for amount of data to be reviewed for the MDM.


----------



## rthames052006 (Mar 14, 2008)

I agree with your statement jbagsic.

Roxanne Thames, CPC





jbagsic said:


> i would credit it for "decision to obtain history from someone other than the patient" for amount of data to be reviewed for the MDM.


----------



## makaplan55 (Mar 14, 2008)

You only need to state who the information was obtained from and why the information was not available from the patient, ie "S/H info obtained from caregiver as patient is demented."


----------



## cedwards (Mar 15, 2008)

Did the patient give the other elements of the PFSH?  Why couldn't the patient give the social history?  Was there something the patient was not telling the physician?  Did the physician ask for the caregiver's info?  I wouldn't credit it to the  "decision to obtain history from someone other than the patient" in the MDM so quickly.  If the patient was demented or intubated or in a coma then you would be able to get credit for PFSH as long as physician documented that s/he was unable to obtain history because pt .... or obtained PFSH from caregiver because pt....


----------

