Documentation Of The Medical History

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