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Complete Family History/Social History

  1. #1
    Default Complete Family History/Social History
    Medical Coding Books
    A provider asked me what he should document in order to obtain credit for a family or social history.

    If he documents only the parents' state of health, is this enough for a conservative auditor to count as family history? Should the provider also document that the patient stated there was nothing else to add to family history?

    If the provider documents tobacco and alcohol use, is this enough to count as social history?

    Any input would be greatly appreciated!

  2. #2
    The statement about tobacco/alcohol satisfies Social History.

    Family history could be a mention of some underlying illness, e.g. hypertention, diabetes, in a parent or sibling. A statement that the Family History is negative (for.....) is also valid. I also have seen something like "Parent alive and well at age ___" and that was acceptable also.

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