decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Answer_Book / Documentation_Guidelines_for_EM_Services / PAST,_FAMILY_AND_OR_SOCIAL_HISTORY_(PFSH)
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Article Overview
This article covers the Past, Family and/or Social History (PFSH) element used in evaluation and management documentation. It describes the three history areas included in PFSH, identifies service categories where PFSH may not be required, and summarizes the general level of history review associated with different E/M service types. It is relevant to clinicians, coders, and documentation specialists working with E/M history requirements.
Why This Topic Matters
Understanding PFSH is important for accurate E/M documentation review and for recognizing when history elements are expected across service categories.
Article Sections
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PFSH overview
Introduces the three areas included in the PFSH component of history documentation.
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When PFSH may not be required
Notes service categories in which interval history may be sufficient without recording PFSH information.
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Pertinent PFSH
Describes the general concept of a pertinent PFSH in relation to the documented history.
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Complete PFSH
Summarizes the broader review level associated with a complete PFSH across different E/M service categories.
What You Will Learn
- The three broad history areas that make up PFSH
- Which E/M service categories are discussed in relation to PFSH documentation
- The distinction between pertinent and complete PFSH at a high level
- How PFSH expectations vary by category of E/M service
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Physicians and other qualified health professionals
- E/M auditors
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