Created byThe Lung Doctor for e-Medtools
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
Created byThe Lung Doctor for e-Medtools
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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Documentation of the Medical History
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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