Daily Bolus of LR: Documentation of the History (PFSH)

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May 12, 2011 by dailybolusoflr

 

Documentation of the History

 

The History is the cornerstone of your chart.

 

It is comprised of FOUR main factors:

 

1.       The Chief Complaint (CC)

2.       The History of Present Illness (HPI)

3.       Review of Systems (ROS)

4.       The Past, Family, and/or Social History (PFSH)

 

It is the first of the essential components for good documentation, as well as for the creation of a billable chart.   Today we will discuss the last one.

 

 

4.       The Past, Family, and/or Social History (PFSH)

 

o   PFSH = Past hx + Family Hx +Social Hx

§  Past includes:

·         Medical and surgical history

·         Medications and Allergies

·         Immunization status

o   Family hx

o   Social

§  Marital status, children,

§  Living situation, employment status

§  Tobacco, alcohol, recreational/illicit drugs

 

o   There are two billing levels

§  Pertinent– 1 specific item from any of the 3 history areas

·         This is required for level 4 charts

§  Complete–1 specific item from 2 of the 3 history areas

·         This is required for level 5 charts

§  Note: Level 1, 2 and 3 charts do NOT require PFSH

 

 

Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions

 

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