Wiki Adequate Family History?

[thelton]

I need opinions from auditors....would you give credit in the family hisotry for the following statement: No relevant family history. Patient is a 4 week old infant with fever and vomiting. Let me know what you think....I don't want to send my docs in the wrong direction! Thanks!!

 

[Peter Davidyock]

I would not credit such a statement. Especially for such a young newborn. The course of pregnancy would be relevant. Something like: Mother states prenancy was uneventful. Question of siblings health would also be relevant. At the very least the physician needs to be stating that the family hx was "reviewed" , not just that it's negative.
That's this auditors 2 cents.