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Family history--what counts

December 29th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Documentation Guidelines   Evaluation & Management (E/M)  
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The Documentation Guidelines describe family history as:

a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk

This family history is a review of the illness's, health status, and cause of death of close members of the patient's family.  The family history may be specific to the disease that the physician is addressing, "No family history of breast cancer in a first order relative," counts as family history for an oncologist evaluating a patient with a breast lump.  Typically, the oncologist would ask about other cancers as well.

If the patient is adopted, and that is stated in the section on family history, that explains why the genetic past of the patient is not known, and is acceptable.

There is carrier variation on whether, "Family history is non-contributory" counts.  To be on the safe side, document a family history for visits which require one.

If the physician is unable to obtain a family history, is sufficient to say that , and why,  "The patient is intubated.  Outside of the history above from the patient's daughter, I was unable to obtain a more complete history."

The guidelines do say, in the introductory section, that the records of infants, children, adolescents and pregnant women may have additional or modified information in each area.  Here is what they say:

As an example, newborn records may include under history of the present illness (HPI) the

details of mother's pregnancy and the infant's status at birth; social history will focus on family

structure; family history will focus on congenital anomalies and hereditary disorders in the

family. In addition, information on growth and development and/or nutrition will be recorded.

Although not specifically defined in these documentation guidelines, these patient group

variations on history and examination are appropriate.

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