The medical history of a patient is one of three principal components required in determining the level of the encounter and the status of the patient (new or established).
A patient’s medical chart contains all the essential data and medical history of the patient, ideally anything medically relevant since birth. It contains not only their current diagnoses, treatments, and vital signs, but also their allergies, progress notes, previous diagnoses and treatment plans, as well as lab, radiology, and test results.
The medical chart is maintained with the information added by the physician, nurse practitioners, nurses, lab techs, and anyone else contributing to their healthcare.
Complete and accurate patient charts are critical to the ongoing treatment of each patient and are also used in the billing process.
What Does a Complete Medical History Contain?
A complete medical history is gathered during a new patient visit. A patient questionnaire is filled out by the patient. The questionnaire is used for building the medical history, followed by questioning by the healthcare staff.
The following information is gathered:
- Personal identification
- Insurance or Financial information
- Previous Medical Events – Past hospitalizations, medications, and treatments
- Family History – Diseases, illnesses, and cause of death of immediate family members
- Social History – Occupation, family status
- Habits – Smoking, drinking, illicit drug use, diet, and exercise (sometimes listed in Social History)
- Medications and allergies
- Surgical History – Operations, procedures, and dates
- Demographics – Age, race (usually listed in History of Present Illness) religion, occupation (traditionally listed in Social History) and contact information (kept in the chart)
- Immunizations – Vaccination status
Three of the major components of the patient’s history are usually grouped together — The Past Medical, Social, and Family History – and referred to simply as the PFSH. There are two different levels of PFSH, and the level required for documenting a medical service will depend on the level and type of visit to be billed.
Each office visit should contain a chief complaint, history of present illness, progress notes, physical exam, assessment, treatment plan, prescriptions, and test results.
Billing a new patient visit includes determining the extra time used for obtaining a detailed medical history and the needed physical exam to diagnose the patient and implement an effective treatment plan.
What is an Interval History?
An interval history is not as in-depth as a comprehensive history and is used for established patient visits. The interval history does not need to have the past medical, social, or family history obtained again. However, the medical record requirement for billing each visit may require documentation that the PFSH was reviewed and verified.