What does a documented past medical history of "Tetanus in 2006" represent in PFSH?

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The documented past medical history of "Tetanus in 2006" is indicative of a complete past, family, and social history (PFSH) for an established patient because it provides significant context regarding the patient's medical background. In an established patient, the physician or coder is looking to gather a comprehensive overview of the patient's past medical issues, including any significant past conditions, treatments, or vaccinations that may impact current health or treatment plans.

In this case, the mention of tetanus, a serious bacterial infection often preventable through vaccination, suggests that the patient has had health interventions in the past, which enriches the understanding of their medical history. Established patients are expected to have a more detailed history already available, and adding past medical conditions contributes to that comprehensive view.

When evaluating PFSH components, the established patient is typically allowed to have a lesser degree of detail compared to a new patient. However, a significant past medical history, such as a vaccination event, would still contribute to making this a complete PFSH for the established patient to adequately inform ongoing care and decision-making processes.

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