Documentation of History

A.            DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive).  Each type of history includes some or all of the following elements:

·           Chief complaint (CC);

·           History of present illness (HPI);

·           Review of systems (ROS); and

·           Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is dependent upon clinical judgement and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history.  To qualify for a given type of history all three elements in the table must be met.  (A chief complaint is indicated at all levels.)

•DG:            The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

•DG:            A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.  This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.  The review and update may be documented by:

·            describing any new ROS and/or PFSH information or noting there has been no change in the information; and

·            noting the date and location of the earlier ROS and/or PFSH.

•DG:            The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient.  To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

•DG:            If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of history are listed below.

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

•DG:            The medical record should clearly reflect the chief complaint.

HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.  It includes the following elements:

·  location,

·  quality,

·  severity,

·  duration,

·  timing,

·  context,

·  modifying factors, and

·  associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

•DG:            The medical record should describe one to three elements of the present illness (HPI).

An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

•DG:            The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

·  Constitutional symptoms (e.g., fever, weight loss)

·  Eyes

·  Ears, Nose, Mouth, Throat

·  Cardiovascular

·  Respiratory  

·  Gastrointestinal

·  Genitourinary

·  Musculoskeletal

·  Integumentary (skin and/or breast)

·  Neurological

·  Psychiatric

·  Endocrine

·  Hematologic/Lymphatic

·  Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

•DG:            The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

•DG:            The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

•DG:            At least ten organ systems must be reviewed.  Those systems with positive or pertinent negative responses must be individually documented.  For the remaining systems, a notation indicating all other systems are negative is permissible.  In the absence of such a notation, at least ten systems must be individually documented.

PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

·            past history (the patient's past experiences with illnesses, operations, injuries and treatments);

·            family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and

·            social history (an age appropriate review of past and current activities).

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH.  Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

•DG:            At least one specific item from any of the three history areas must be documented for a pertinent PFSH .

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service.  A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient.  A review of two of the three history areas is sufficient for other services.

•DG:            At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; domiciliary care, established patient; and home care, established patient.

•DG:            At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.