The medical history is one of the three key components of every patient encounter, whether initial or subsequent, for hospital inpatient or observation care, or as an attending or a consultant. Correct handling of the documentation of the patient's history is not only necessary for patient care, but also crucial for correct evaluation and management (E&M) coding and reimbursement. Most discussions of these E&M requirements focus on the technical coding elements, but a clinical approach to documenting the medical history makes more sense for physicians.
The technical components of the history include chief complaint (CC); history of the present illness (HPI); past, family and social history (PFSH); and review of systems (ROS). The elements of each are shown in the sidebar below.
The hospitalist's approach to these components should follow the familiar sequence of clinical data collection. The chief complaint is a brief statement of the presenting problem, usually in the patient's own words—easy enough. The remaining components are described in further detail below.
History of the present illness
Every physician is familiar with the usual clinical objectives of the HPI and records this information effortlessly by asking:
- What? (primary and associated symptoms, their nature and quality, and their severity)
- When? (onset, duration, progression and timing of progression)
- Where? (location and radiation)
- How? (exacerbating or relieving factors, context and modifying factors)
Past, family and social history
In clinical practice, the past, family and social histories are typically recorded as separate categories and not lumped together as one (PFSH). The E&M “past history” is, in actual practice, subdivided into categories such as allergies, medications, immunizations, operations, hospitalizations and/or history of active and inactive past medical problems and conditions (also commonly referred to as past medical history).
Any physician obtaining history from a patient for the first time would usually make some reference to each of these categories. No change in this common clinical practice is necessary for accurate coding, but a specific reference to both family and social history should always be included.
Review of systems
The greatest challenge in medical history-taking is documentation of the review of systems (ROS). From a clinical standpoint the ROS is essential for quality patient care, but it sometimes gets short shrift. Every new patient deserves a review of most, if not all, of the 14 systems. Time constraints may make this a difficult task. Fortunately, there are several potential solutions to this dilemma:
- The physician can perform the ROS during the physical exam, inquiring about symptoms as each area is examined.
- An ROS form completed by patient, family or staff can be used if actually “reviewed” by the physician—in other words, authenticated and dated with pertinent notations or comments.
- Reference to another clinician's ROS can be made, as long as its location is listed, its content is verified and any pertinent changes or comments are made. The physician should ensure that the other clinician's ROS is accurate and reliable.
- If the patient is unable to cooperate and others are not available to give the information, a clinician may document: “Unable to obtain because… [specific reason].”
- The pertinent ROS positive or negative findings can be documented combined with the statement (if it's true), “All other systems reviewed and negative.”
When these logical clinical steps are followed, a thorough initial history (admission or consultation) for every patient can be accomplished efficiently without concern for the technicalities of E&M coding demands.
Such comprehensive detail is rarely necessary or appropriate for subsequent inpatient visits (progress notes). In those cases, the documentation will reflect primarily current problems and complaints. E&M code assignment for subsequent inpatient visits depends almost exclusively on physical examination and medical decision-making components, not history.
In summary, every new patient admitted to the hospital deserves a complete and comprehensive history. Include a chief complaint and record the what, when, where and how of the HPI. Make notations regarding past, social and family history. Past history includes such things as allergies and medications, among others. Use tools and strategies to collect a 14-system ROS accurately and efficiently. Apply the information gathered to provide the patient with the best professional care possible.