Originally published March 10, 2020. Payer rules change; confirm current CMS and payer requirements before billing.
The patient's medical history is one of three key components used to determine the level of an encounter and the patient's status (new or established).
A patient's medical chart holds all of the patient's essential data and history, ideally anything medically relevant since birth. It includes current diagnoses, treatments and vital signs, as well as allergies, progress notes, previous diagnoses and treatment plans, and lab, radiology and test results.
The chart is maintained by the physician, nurse practitioners, nurses, lab technicians and anyone else involved in the patient's care. Complete and accurate charts are critical for ongoing treatment and are also used in billing.
What a complete medical history contains
A complete medical history is gathered at a new patient visit. The patient fills out a questionnaire, and staff follow up with questions. The following information is collected:
- Personal identification
- Insurance or financial information
- Previous medical events: past hospitalizations, medications and treatments
- Family history: diseases, illnesses and causes of death of immediate family members
- Social history: occupation, family status
- Habits: smoking, drinking, drug use, diet and exercise (sometimes listed under social history)
- Medications and allergies
- Surgical history: operations, procedures and dates
- Demographics and contact information
- Immunizations
Past medical, family and social history are usually grouped together as PFSH. There are two levels of PFSH, and the level needed depends on the level and type of visit billed.
Each office visit should include a chief complaint, history of present illness, progress notes, physical exam, assessment, treatment plan, prescriptions and test results.
A new patient visit accounts for the extra time needed to take a detailed history and perform the exam needed to diagnose the patient and build a treatment plan.
What an interval history is
An interval history is less detailed than a comprehensive history and is used for established patient visits. Past medical, family and social history don't need to be collected again, but billing documentation may need to show that the PFSH was reviewed and verified.