Notes on the Documentation of History

** 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.

** 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:

• 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.

** 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.

** 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.