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Documentation of the Medical History

Documentation of the Medical History

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A brief summary of the History component of medical documentation based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the Demystifying Medical Documentation presentation.
A brief summary of the History component of medical documentation based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the Demystifying Medical Documentation presentation.

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Published by: adultmedicalconsultants on Nov 01, 2008
Copyright:Traditional Copyright: All rights reserved

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05/21/2013

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The HistoryThe History
 
History Components and LevelsHistory Components and Levels
ComprehensiveCompleteCompleteExtended  Detailed Pertinent Extended Extended  Expanded Problem Focused N/AProblem pertinent Brief Problem Focused N/AN/ABrief 
Type of HistoryPFSHROSHPI
New patient evaluations MUST have at least a
Detailed History 
 
History of Present IllnessHistory of Present Illness
EVERY encounter MUST contain a Chief Complaint!
Preferentially stated in patients’ words
Elements of HPI
LocationQualitySeverityDurationTimingContextModifying factorsAssociated Signs and Symptoms
Brief 
Contains 1-3 elements listed
Extended 
Contains
4 elementsOR discusses 3 chronic or inactive conditions

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