The History
Created by The Lung Doctor for e-Medtools
History Components and Levels HPI Brief
ROS N/A
PFSH N/A
Type of History Problem Focused
Brief
Problem pertinent
N/A
Expanded Problem Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
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
Created by The Lung Doctor for e-Medtools
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)
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