DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: 

• Chief complaint (CC); 
• History of present illness (HPI); 
• Review of systems (ROS); and 
• Past, family and/or social history (PFSH)

The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

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 re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/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: 

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and 

o 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 which 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.