Wiki Use of social history in E/M determination

[trinalankford]

Are you able to count "social history" as an element of your HPI determination if there is a discrepancy in that information? Example: It is documented in one location as "ex-smoker" (or "former smoker" or similar) but in another location as "smokes cigarettes daily." I'm thinking you cannot because the tobacco usage hasn't been completely clarified, but I cannot document this anywhere.

Thanks!

 

[blaymon]

I would think you are correct. Smoking use would have to be clarified and then it could only be used as an element of the Social History.