Medical Documentation: Medical History

Documentation of the Medical History

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The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint!  Preferentially stated in patients’ words Elements of HPI Location Brief Quality Contains 1-3 elements listed Severity Extended Duration Contains ≥ 4 elements Timing OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Documents responses to the system directly related to the presenting problem Extended Documents positive and negative responses to 2-9 systems related to the problem Complete Documents all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total) Created by The Lung Doctor for e-Medtools Past, Family and Social History Past Medical History  Illnesses, Operations, Injuries and Treatments Family Medical History  Include heritable diseases and those that place the patient at increased risk Social History  An age appropriate review of past and current activities Pertinent Document at least 1 item from ANY of the 3 areas It must be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for the medical history based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.