1995 DocumentationTION GuidelinesIDELINES for ­Evaluation and ­ManaALUATION AND mANAgement Services ||||||||||| 361 Appendix A CPT copyright 2015 American Medical Association. All rights reserved. •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 rerecorded 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 E E Describing any new ROS and/or PFSH information or noting there has been no change in the information E E 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 that 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. •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: E EE Location EE Quality EE Severity EE Duration EE Timing EE Context EE Modifying factors E Associated signs and symptoms Brief and extended HPIs are distinguished by the amount of detail needed to accurately character- ize 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 four or more elements of the HPI. •DG: The medical record should describe four or more elements of the present illness (HPI) or associated co-morbidities. 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 that the patient may be experiencing or has experienced. For purposes of ROS, the following systems are recognized: E EE Constitutional symptoms (eg, fever, weight loss) EE Eyes EE Ears, nose, mouth, throat EE Cardiovascular EE Respiratory EE Gastrointestinal EE Genitourinary E Musculoskeletal
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