Wiki social history consideration

[jcullins01]

i am an emergency dept medical coder, during a recent meeting the subject of can "domestic violence, abuse" be considered a "social hx" was brought to the table. I agree that this would be considered a social history some of my associates did not. Can someone clarify this and supply any reference material from which i can support this claim. The only thing that I am getting from the CPT book under social hx is "other relevant social factors" outside of the obvious.

 

[BLUCIANI]

This is a social history and would affect the treatment of the patient.
BL- CPC

 

[MnTwins29]

1995 and 1997 E/M Documentation Guidelines:

Under PFSH, here is the definition:

"social history (an age appropriate review of past and current activities)."

Certainly, domestic abuse would qualify as this.

 

[MarcusM]

I would vote as including in Social History. Since the abuse is mentioned, then it clearly is a factor in evaluation and treatment(s).

Social is defined as: Of or relating to human society, the interaction of the individual and the group, or the welfare of human beings as members of society; Living together in communities. (Sometimes we live well within the community, sometimes not so much as in the case of domestic violence.)

Medical history from http://www.medilexicon.com/medicaldictionary.php?t=41172

Definitions:
1. a narrative or record of past events and circumstances that are or may be relevant to a patient's current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts. More formally, a comprehensive statement of facts pertaining to past and present health gathered, ideally from the patient, by directed questioning and organized under the following heads.
Chief Complaint (CC): a brief statement of the complaint or incident that prompted medical consultation.
History of Present Illness (HPI): a detailed chronologic narrative, as much as possible in the patient's own words, of the development of the current health problem from its onset to the present.
Past Medical History (PMH): prior illnesses, their treatments and sequelae.
Social History (SH): marital status, past and present occupations, travel, hobbies, stresses, diet, habits, and use of tobacco, alcohol, or drugs. (domestic abuse would clearly be a stressor)
Family History (FH); present health or cause of death of parents, brothers, sisters, with particular attention to hereditary disorders.
Review of Systems (ROS): an exhaustive survey of symptoms or diseases, organized by body system, not covered in previous parts of the history.

 

[jcullins01]

Thank you so much, this helps out a lot.