Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History

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Areas of the Past, Family and Social History

The areas of the Past, Family and Social History (PFHS) are:

1. Past. This area includes illnesses, operations, treatments and injuries that the patient has had in the past.

2. Family. It includes a review of relevant medical events in close family members. It also explores the possibility of these conditions being hereditary .

3. Social. This area includes the activities that the patient is involved with. In this area, negative habits such as smoking of intake of illegal drugs are explored

Bibliography

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. "Evaluation and Management Services." Accessed April 1, 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Marco A. Ramos MD, CCDS

In order to quote from this article in bibliography, Chicago style, please use the following:

Ramos, Marco. “Clinical Documentation Improvement Series 18. Evaluation and Management Documentation 3. Areas of the Past, Family and Social History”. SMO Blog (blog). April1, 2020.https://hive.blog/health/@secondmedicalop/clinical-documentation-improvement-series-18-evaluation-and-management-documentation-3-areas-of-the-past-family-and-social

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies

- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.

- Clinical Documentation Improvement Series #6. Substance Dependence and Associated Conditions.

- Clinical Documentation Improvement Series #7. Inpatient versus Observation

- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”

- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...

- Clinical Documentation Improvement Series #10. Documenting Pneumonia

- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…

- Clinical Documentation Improvement Series #12. Documentation of Acute Kidney Failure

- Clinical Documentation Improvement Series #13. Documenting Liver Failure

- Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1

- Clinical Documentation Improvement Series #15. General Advise (Tip #2)

- Clinical Documentation Improvement Series 16. Evaluation and Management Documentation 1. Components of the History of Present Illness

- Clinical Documentation Improvement Series 17. Evaluation and Management Documentation 2. Individual Systems of the Review of Systems

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