E/M PFSH Element Flashcards

Questions and Answers

What term suggests that the patient is well known to the physician?

established patient

What term connotes an initial visit between the patient and physician?

new patient

What is one of the three elements of history?

PFSH

What is the definition of 'history' in a medical context?

the patient's personal experience and descriptions of the current health complaint, the status and function of the patient's body, as well as past medical history, genetic medical history, and/or any social habits which may impact the patient's health Signup and view all the answers

What is the term for the documentation of two or three elements of a patient's past, family, social history?

complete Signup and view all the answers

What is the term for the documentation of only one element of the patient's past, family, social history?

pertinent Signup and view all the answers

What does 'social history' encompass?

alcohol or tobacco use Signup and view all the answers

What does the term 'past history' refer to?

patient had a fractured tibia at age 8 Signup and view all the answers

How many levels of past, family, social history are identified in the 1995 and 1997 Documentation Guidelines for Evaluation and Management?

Two Signup and view all the answers

What does the acronym 'PFSH' stand for?

Past, family, social history Signup and view all the answers

What is the 'past, family, social history'?

An element of history, which illustrates the background of the patient's life Signup and view all the answers

What does 'social history' reflect?

The patient's social activities and how these social activities may impact the patient's health Signup and view all the answers

Which of the following does NOT relate to social history?

Prescribed medications Signup and view all the answers

Which of the following does NOT relate to past history?

Previous living arrangements Signup and view all the answers

Which of the following does NOT relate to family history?

The medical history of the patient's current partner or spouse Signup and view all the answers

Which of the following BEST supports 'past history'?

Patient has a history of recurrent pneumonia prior to age 10 Signup and view all the answers

What does the documentation indicating that a patient’s paternal grandmother died of bone cancer represent?

family history Signup and view all the answers

Study Notes

Patient Identification

An established patient is one well known to the physician, indicating a prior relationship.
A new patient refers to someone visiting the physician for the first time, representing an initial consultation.

History Components

PFSH stands for Past, Family, and Social History, an essential element of patient history.
The term history encompasses the patient’s personal experience regarding their current health issue, overall body function, past medical history, genetic background, and social habits that may affect health.

Documentation Types

Complete documentation includes details on two or three elements of the patient's past, family, and social history.
Pertinent documentation involves only one element of the patient's past, family, and social history, providing focused information.

Social history includes lifestyle factors like alcohol or tobacco use, which can significantly influence health outcomes.
Past history refers to previous medical issues the patient has experienced, such as a fractured tibia at age 8.

Evaluative Guidelines

The 1995 and 1997 Documentation Guidelines for Evaluation and Management identify two levels of past, family, social history: Pertinent and Complete.
An understanding of the past, family, and social history is crucial as it reflects the patient's life background and health influences.

Evaluating Health Impact

Social history captures the patient’s social activities and examines their potential effects on health.
Items not considered part of social history include prior surgeries, illnesses, or prescribed medications.

Distinguishing Histories

Previous living arrangements do not pertain to past history, which primarily includes medical conditions and treatments.
The medical history of a patient’s current partner is not part of family history.

Illustrative Examples

An example of past history is when a patient has a documented history of recurrent pneumonia before age 10.
Documentation of the paternal grandmother's death from bone cancer in patient records qualifies as family history, emphasizing familial health patterns.

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Description

Test your understanding of the E/M PFSH elements with these flashcards. This quiz covers essential terminology related to established and new patients, as well as the components of patient history. Perfect for medical students or professionals looking to refresh their knowledge.