Certified Risk Adjustment Coder (CRC)

Which component of a patient's history is NOT included in PFSH?

1. Chronic diseases.

2. Social habits.

3. Family health history.

4. Physical examination results.

The correct answer is: Physical examination results.

The assessment of a patient's history, particularly in the context of the PFSH (Past Medical, Family, and Social History), is an essential part of a comprehensive evaluation. The PFSH consists of three main components: past medical history, family history indicating hereditary factors, and social history that encompasses social habits and lifestyle practices. Physical examination results do not fall under the PFSH category. Instead, they are part of the clinical assessments performed by healthcare providers during the patient’s visit. The physical examination focuses on the objective findings and indicators that result from hands-on examination techniques, including observation, palpation, percussion, and auscultation. It is distinct from history-taking, which aims to gather information about the patient’s previous medical conditions, family’s health background, and social activities that may impact health. By contrast, chronic diseases, social habits, and family health history all provide crucial context about the patient’s overall health and potential risk factors. These components inform treatment plans and highlight areas requiring closer monitoring, aiding in the understanding of how personal and familial patterns of illness may influence the patient's care. Therefore, the principal distinction lies in the nature of the information collected: PFSH is focused on subjective history information, while physical examination results are objective