Wiki Family hx for Inpatient Consult missing

[wynonna]

So if a provider did not document a family history at all in PFSH section, but the patient is established since we saw him in the office 1 year ago. For other areas of Past, Family & Social History, the provider documented 3 under Past medical history and 1 under Social history.
(And there are 4 details in HPI, and 3 elements under ROS)
If Family history is missing from note, would this be a Expanded Problem focused history or Detailed? (If everything else is as the above)
Thanks

 

[wisibyusha]

If I have understood the documentation correctly, you have for HPI 4 elements which takes it to extended HPI, you have 3 elements under ROS which takes it to extended ROS, and under PFSH you have at least 2 elements which takes it to Pertinent PFSH. So now in order to find the extent of history 3/3 key components have to be met and that takes you to detailed history. Even if you have 4 elements as stated by the provider, you will still end up at extended history because your ROS is extended and not complete. Hope that helps.