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

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: 

• Chief complaint (CC); 
• History of present illness (HPI); 
• Review of systems (ROS); and 
• Past, family and/or social history (PFSH). 

The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)  

History of Present Illness (HPI)	Review of Systems (ROS)	Past, Family, and/or Social History (PFSH)	Type of History
Brief	N/A	N/A	Problem Focused
Brief	Problem Pertinent	N/A	Expanded Problem Focused
Extended	Extended	Pertinent	Detailed
Extended	Complete	Complete	Comprehensive

DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. 

DG: A ROS and/or a PFSH obtained during an earlier encounter does 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/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:

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and 

o noting the date and location of the earlier ROS and/or PFSH

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 

DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: 

• Chief complaint (CC); 
• History of present illness (HPI); 
• Review of systems (ROS); and 
• Past, family and/or social history (PFSH)

The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. 

DG: A ROS and/or a PFSH obtained during an earlier encounter does 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/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: 

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and 

o noting the date and location of the earlier ROS and/or PFSH. 

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 

DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of history are listed below. 

CHIEF COMPLAINT (CC) 

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. 

DG: The medical record should clearly reflect the chief complaint.