PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

There are three basic history areas required for a complete PFSH:

1. Past medical/psychiatric history: Illnesses, operations, injuries, treatments

2. Family history: Family medical history, events, hereditary illnesses 

3. Social history: Age-appropriate review of past and current activities 

The data elements of a textbook psychiatric history, listed below, are substantially more complete than the elements required to meet the threshold for a comprehensive or complete PFSH:

• Family history 

• Birth and upbringing 

• Milestones 

• Past medical history 

• Past psychiatric history 

• Educational history

• Vocational history 

• Religious background 

• Dating and marital history 

• Military history

• Legal history 

The two levels of PFSH are:

1. Pertinent, which is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document one item from any of the three history areas. In the following example, the patient’s past psychiatric history is reviewed as it relates to the current HPI:

• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac. Episode lasted 3 months.

2. Complete. At least one specific item from two of the three basic history areas must be documented for a complete PFSH for the following categories of E/M services:

• Office or other outpatient services, established patient 

• Emergency department 

• Domiciliary care, established patient 

• Home care, established patient 

At least one specific item from each of the three basic history areas must be documented for the following categories of E/M services:

• Office or other outpatient services, new patient 

• Hospital observation services 

• Hospital inpatient services, initial care 

• Consultations 

• Comprehensive nursing facility assessments 

• Domiciliary care, new patient 

• Home care, new patient  

Documentation of History. Once the level of history is determined, documentation of that level of HPI, ROS, and PFSH is accomplished by listing the required number of elements for each of the three components

An ROS and/or PFSH taken during an earlier visit need not be rerecorded if there is evidence that it has been reviewed and any changes to the previous information have been noted. The ROS may be obtained by ancillary staff or may be provided on forms completed by the patient. The clinician must review the ROS, supplement and/or confirm the pertinent positives and negatives, and document the review. By doing so, the clinician takes medical-legal responsibility for the accuracy of the data. If the condition of the patient prevents the clinician from obtaining a history, the clinician should describe the patient’s condition or the circumstances that precluded obtaining the history. Failure to provide and record the required number of elements of the ROS for the level of history designated is the most frequently cited deficiency in audits of clinicians’ mental health records.