Aspects of PFSH
Published on Thu May 05, 2011
Per CPT®, past medical, family and/or social history is divided into three subsections.
1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, coding lead at a practice in St. Paul, Minn., including:
- prior major illnesses and injuries
- prior operations
- prior hospitalizations
- current medications
- allergies
- age-appropriate immunization status
- age-appropriate feeding/dietary status.
Examples:
"Patient has spina bifida; patient had a kidney stone episode 12 years ago; patient is allergic to penicillin; patient had a thyroidectomy in 2009."
2. Family history
includes a review of health-related events in the patient's family, including:
- health status or cause of death of parents, siblings, and children
- specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
- diseases of family members that may be hereditary or place the patient at risk.
Examples:
"Both siblings have schizophrenia; mother died at 55 of breast cancer; father has COPD."
3. Social history
covers past and current activities related to:
- marital status and/or living arrangements
- current employment
- occupational history
- use of drugs, alcohol and tobacco
- level of education
- sexual history
- other relevant social factors
- activities that include sun and/or chemical exposure.
Examples:
"Patient is an avid golfer; patient grew up on a farm drinking well water; patient is a smoker; patient attends daycare; patient lives in a group home."