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Last Modified: 12/6/2018 Location: FL, PR, USVI Business: Part A, Part B

Past, family and/or social history (PFSH)

Q. If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?
A. If the record indicates that the patient’s past, family, and/or social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be clearly documented in the medical record.
Source: Provider Outreach and Education
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