Let’s Get Social About Social History
Paul Spencer, CPC, COC
Senior Compliance Consultant at DoctorsManagement
This auditing and compliance “Tip of the Week” was originally published by the
National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.
In the template-driven world of physician documentation thrust upon us as auditors, the portion of the Evaluation and Management (E/M) History component known as Past, Family & Social History (PFSH) is often a case of “is it or is it not there”. The “Past” and “Family” portions of PFSH are fairly straightforward, but recently a colleague came to me discussing Social History, and points of contention that were raised about what might be documented in this portion of PFSH.
Both sets of E/M Guidelines only refer to social history as “an age-appropriate review of past and current activities”. Activities that affect health are usually listed categorically, with items within those categories becoming self-evident as they relate to the health of the patient:
Smoking history, alcohol intake and drug use – Over 50 years of clinical studies have indicated the risks associates with these types of activities. As auditors, the term “age-appropriate” applies to smoking in particular, as there have been times as an auditor where smoking history has been used on children under 10, but bear in mind that this could also apply to second-hand smoke exposure.
Marital status or living condition – If the patient is divorced or widowed, or has had a sudden change related to housing/shelter, this can possibly have an effect on the patient’s overall well-being at the time of the encounter. In addition, a simple statement of “married”, technically meets the standard of the E/M guidelines.
Sexual history – The narrative in this section may tie in to marital status, and can also be indicators related to the chief complaint.
Employment status – The stresses, or conversely the sedentary nature of the patient’s employment, can provide a window into symptomology.
Educational information – This applies more to patients of a younger age, as it relates to attention deficits, difficulties with tasks and current grades. This is sometimes combined with employment status in the specialties of Neurology and Psychiatry.
Other relevant social factors – As it relates to the chief complaint and the history of present illness, the biggest of remaining social history information can relate to contact with others that have similar symptomology. For children in particular, information on daily child care can greatly expedite the diagnostic process.
As we see from the examples above, there are many paths to the simple documentation of a social history. Even with template-driven documentation, social history need not be a point of stress. Simple statements linking back to and supporting other elements of the history will suffice.
What to do next…
- Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
- Read more: What can you expect from a coding and compliance review?
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