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.

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:

• location; 
• quality; 
• severity;
• duration; 
• timing; 
• context; 
• modifying factors; and 
• 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 four or more elements of the HPI. 

DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.

REVIEW OF SYSTEMS (ROS) A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. 

For purposes of ROS, the following systems are recognized:

• Constitutional symptoms (e.g., fever, weight loss) 
• Eyes
•  Ears, Nose, Mouth, Throat 
• Cardiovascular 
• Respiratory 
• Gastrointestinal 
• Genitourinary 
• Musculoskeletal 
• Integumentary (skin and/or breast)
•  Neurological 
• Psychiatric
• Endocrine 
• Hematologic/Lymphatic 
• Allergic/Immunologic 

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.