1997 DocumentationTION GuidelinesIDELINES for ­Evaluation and ­ManaALUATION AND mANAgement Services ||||||||||| 369 Appendix A CPT copyright 2015 American Medical Association. All rights reserved. History of Present Illness Review of Systems Past, Family, and/or Social History Type of History Brief N/A N/A Problem focused Brief Problem pertinent N/A Expanded problem focused Extended Extended Pertinent Detailed Extended Complete Complete Comprehensive •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 recom- mended 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: 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 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.
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