Please identify the overall Hx level. History can provide greater ...

[abern]

Please identify the overall Hx level. History can provide greater information about the patient's story of health in relation to the CC. How does the documented history in this clinical note do this?
 
  What will be an ideal response?

Question 2

Please identify the patient type, the documented PFSH elements and the supporting findings. How does the patient type and documented PFSH provide greater information about the CC, HPI, ROS and the professional relationship between patient and physician performing the E/M service?
 
  What will be an ideal response?

[duy1981999]

Answer to Question 1

The overall history level is Detailed.
While the HPI describes the CC, and the ROS describes the state of the patient's health prior to the E/M service, the PFSH provides a more revealing portrayal of the patient's entire life. All of these elements together provide a mosaic of the patient's health from the perspective of the CC.

Answer to Question 2

PFSHPertinent:
PMH: CABG 2002
FMH: None documented
SH: None documented

Generally, the PFSH provides information about the patient's life in addition to the story of the patient's health: while past history informs the reader about the patient's past medical history, the social and family histories inform the reader about the rest of the patient's life from the perspective of the CC. The patient type provides information about how familiar the physician is with the patient's story of health.

[abern]

TYSM

[alexanderhamilton]

Excellent