What counts as social history?

July 27th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Documentation Guidelines   Evaluation & Management (E/M)  
 

The Documentation Guidelines say social history is:

an age appropriate review of past and current activities.

As auditors, we interpret this to include:

In order to credit social history in a note, any one of those must be reviewed.  There is no requirement that all of them are reviewed.  There is no description in the guidelines of how extensive the social history must be.  Most auditors count it if one of the above are present.


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Source:  http://www.codapedia.com//article_202_What_counts_as_social_history%3F.cfm