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 Metro Urology 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.
Examples: "Patient is recently married and is a stay-at-home parent; patient is a smoker; patient attends daycare; patient lives in a group home."
