Practice Management

Document Patient History


Documentation in the medical record serves many purposes: communication among healthcare professionals, evidence of patient care, and justification for provider claims.

Although these three aspects of documentation are intertwined, the first two prevent physicians from paying settlements involving malpractice allegations, while the last one assists in obtaining appropriate reimbursement for services rendered. This is the first of a three-part series that will focus on claim reporting and outline the documentation guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA).

1995, 1997 Guidelines

Two sets of documentation guidelines are in place, referred to as the 1995 and 1997 guidelines. Increased criticism of the ambiguity in the 1995 guidelines from auditors and providers inspired development of the 1997 guidelines.

While the 1997 guidelines were intended to create a more objective and unified approach to documentation, the level of specificity required brought criticism and frustration. But while the physician community balked, most auditors praised these efforts.

To satisfy all parties and allow physicians to document as they prefer, both sets of guidelines remain. Physicians can document according to either style, and auditors are obligated to review provider records against both sets of guidelines, selecting the final visit level with the set that best supports provider documentation.

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Elements of History

Chief complaint (CC): The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).

History of present illness (HPI): This is a description of the present illness as it developed. It is typically formatted and documented with reference to location, quality, severity, timing, context, modifying factors, and associated signs/symptoms as related to the chief complaint. The HPI may be classified as brief (a comment on fewer than HPI elements) or extended (a comment on more than four HPI elements). Sample documentation of an extended HPI is: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”

The 1997 guidelines offer an alternate format for documenting the HPI. In contrast to the standard method above, the physician may list and status the patient’s chronic or inactive conditions. An extended HPI consists of the status of at least three chronic or inactive conditions (e.g., “Diabetes controlled by oral medication; extrinsic asthma without acute exacerbation in past six months; hypertension stable with pressures ranging from 130-140/80-90”). Failing to document the status negates the opportunity for the physician to receive HPI credit. Instead, he will receive credit for a past medical history.


The general principles of medical record documentation for evaluation and management (E/M) services are as follows:

  • The medical record should be complete and legible;
  • Documentation of each patient encounter should include at minimum: the reason for the visit, relevant history, physical exam findings and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer;
  • The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred;
  • Past and present diagnoses should be available to the treating and/or consulting physician;
  • Appropriate health-risk factors should be identified;
  • Document patient progress, response to and changes in treatment, and revision of diagnosis; and
  • Documentation should support the CPT and ICD-9-CM codes reported for billing.

Some of these principles may be adjusted as reasonably necessary to account for the varying circumstances encountered by physicians when providing E/M services.—CP

The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).

Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:

  • Constitutional;
  • Eyes; ears, nose, mouth, throat;
  • Cardiovascular;
  • Respiratory;
  • Gastrointestinal;
  • Genitourinary;
  • Musculoskeletal;
  • Integumentary (including skin and/or breast);
  • Neurological;
  • Psychiatric;
  • Endocrine;
  • Hematologic/lymphatic; and
  • Allergic/immunologic.

The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).

Documentation of a complete ROS (more than 10 systems) can occur in two ways:

  • The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or
  • The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.

Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.

Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).

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Levels of History

There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.

If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.


Case 1 (deficient history): The hospitalist documents a problem-focused history (“no new events overnight”) after providing subsequent hospital care to a patient with uncontrolled diabetes mellitus, hypertension, status post hip repair. If documentation supports a detailed examination and medical decision making of high complexity, can the hospitalist appropriately report 99233 (subsequent hospital care requiring two of three key components: detailed history, detailed examination, high-complexity decision making)?

The Solution

Yes. Visit level selection is based upon three “key” components: history, exam, and medical decision-making. Some visit categories allow for visit level selection based on two of the three key components (e.g., subsequent hospital care) while others consider all three components (e.g., initial hospital care, inpatient consultations, and initial observation care). Although the “problem-focused” documentation involving the history component is insufficient for reporting 99233, visit-level selection for subsequent hospital care is based upon two key components. Since the hospitalist documented a detailed exam and high-complexity decision making, reporting 99233 is acceptable.

Case 2 (unable to obtain): Upon admission to the hospitalist service, an 82-year-old female presents with shortness of breath, dehydration, and confusion. The patient was transferred from her residence at a nursing facility without accompanying records. Limited information was obtained by the emergency medical technician, and the patient is an unreliable source. The available information is documented, but the level of history is only expanded problem-focused. Can the hospitalist receive additional credit for the history?

The Solution

Yes. The documentation guidelines specifically reference this situation. When the physician cannot elicit historical information from the patient, and no other source is available, the physician should document that he is “unable to obtain” the history and the circumstances surrounding this problem (e.g., patient confused, no caregiver present).

The hospitalist can receive “complete history” credit for his attempted efforts.—CP