The Past, Family and/or Social History (PFSH) includes a review in three areas:

  1. Past History: The patient’s past illnesses, operations, injuries, medications, allergies and/or treatments
  2. Family History: The review of the patient’s family and their medical events, including diseases which may be hereditary or place the patient at risk
  3. Social History: An age appropriate review of past and current activities (i.e. job, marriage, exercise, marital status, etc.)

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the History of Present Illness (HPI). At least one specific item from any of the three history areas must be
documented for a pertinent PFSH.

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the Evaluation and Management (E/M) service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.

The PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

A PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

  • Describing any new PFSH information or noting there has been no change in the information; and
  • Noting the date and location of the earlier ROS and/or PFSH

The PFSH may be recorded by ancillary staff or on a form completed by the patient.To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.