Created by The Lung Doctor for e-Medtools

The HistoryThe History

Created by The Lung Doctor for e-Medtools

History Components and Levels History Components and Levels

HPI ROS PFSH Type of History

Brief N/A N/A 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 IllnessHistory of Present IllnessEVERY encounter MUST contain a Chief Complaint!

Preferentially stated in patients’ words

Elements of HPILocation

QualitySeverityDurationTimingContextModifying factorsAssociated Signs and Symptoms

BriefContains 1-3 elements listed

ExtendedContains 4 elements

OR discusses 3 chronic or inactive conditions

BriefContains 1-3 elements listed

ExtendedContains 4 elements

OR discusses 3 chronic or inactive conditions

Created by The Lung Doctor for e-Medtools

Review of SystemsReview of SystemsConstitutional SymptomsEyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary (Skin, Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/Immunologic

Problem PertinentDocuments responses to the system directly related to the presenting problem

ExtendedDocuments positive and negative responses to 2-9 systems related to the problem

CompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)

Problem PertinentDocuments responses to the system directly related to the presenting problem

ExtendedDocuments positive and negative responses to 2-9 systems related to the problem

CompleteDocuments 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 HistoryPast, 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

PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI

PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI

Complete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areas