Name of the Condition

• Personal History of Adult Physical and Sexual Abuse
• ICD-10 Code: Z91.410

Summary

• This code is used to indicate a personal history of physical and sexual abuse experienced during adulthood. It is important for healthcare providers to be aware of this history to offer appropriate support and interventions.

Causes

• The condition refers to the history of abuse rather than an active condition with causes. However, trauma from physical or sexual abuse can lead to various health and psychological issues.

Risk Factors

• Being in an abusive relationship.
• Having a history of abuse in childhood.
• Lack of support systems.
• Socioeconomic stress factors.

Symptoms

• This ICD code itself does not describe symptoms but acknowledges a history that may contribute to psychological conditions such as PTSD, anxiety, or depression.

Diagnosis

• This history is generally obtained through patient interviews and health assessments to understand their past experiences and provide proper care.

Treatment Options

• Counseling and therapy, such as Cognitive Behavioral Therapy (CBT), can help manage effects of past abuse.
• Support groups provide community and understanding.
• Medical treatment may be necessary for any physical injuries sustained from past abuse.

Prognosis and Follow-Up

• Many individuals benefit from psychological therapy and social support.
• Regular follow-ups can help monitor mental health and provide continued support.

Complications

• Long-term mental health issues including depression, PTSD, or anxiety.
• Potential for chronic physical health issues as a result of untreated injuries.

Lifestyle & Prevention

• Engaging in supportive social connections and seeking professional help when needed.
• Stress management techniques like meditation and regular physical activity.

When to Seek Professional Help

• Symptoms of emotional distress, including depression, anxiety, flashbacks, or nightmares.
• Physical symptoms that could be related to past injuries.
• Engagement in self-destructive behaviors.

Additional Resources

• National Domestic Violence Hotline: 1-800-799-7233
• RAINN (Rape, Abuse & Incest National Network): rainn.org

Tips for Medical Coders

• Accurate coding of history should be noted if discussed during consultations.
• Ensure appropriate documentation justifies the code usage.
• Avoid coding current abuse incidents under this history code; use appropriate abuse codes instead.