Daily Bolus of LR: Documentation of the History (CC and HPI)

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May 9, 2011 by dailybolusoflr

Documentation of the History

 

The History is the cornerstone of your chart.

 

It is comprised of FOUR main factors:

 

1.       The Chief Complaint (CC)

2.       The History of Present Illness (HPI)

3.       Review of Systems (ROS)

4.       The Past, Family, and/or Social History (PFSH)

 

It is the first of the essential components for good documentation, as well as for the creation of a billable chart.   Today we will discuss the first two.

 

1.       The Chief Complaint

 

a.       This is the patient’s own words and is a short statement describing why the patient is there.

b.      Anyone can document the chief complaint (RN, student etc)

 

2.       The HPI

 

a.       There are 8 possible elements of “History of Present Illness”

·         Location – Where the symptom or problem is occurring

·         Severity –  A rating or description of severity of the symptom or pain

·         Timing – When symptom or pain occur

·         Quality – The character of the sign or symptom

·         Duration – How long a pain or symptom lasts, has been present, or persisted

·         Associated signs/symptoms – Any organ system or body area complaints associated with the chief complain

·         Context – Instances or items that can be associated with the chief compliant

·         Modifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse

 

b.      Two Levels

·         Brief – 1-3 elements (1 element is acceptable for charts with Billing LEVELS 1, 2, and 3)

·         Extended – 4 or more elements  (This is required for your Billing LEVEL 4 and 5 charts)

 

 

 

Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions

 

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