1997 Evaluation and Management Documentation Guidelines

Why This Topic Matters

Accurate documentation is central to selecting and supporting evaluation and management services, and this guidance helps readers understand the structure behind those expectations. It is useful for improving compliance, claim support, and consistency across clinical records.

Article Sections

1. I. Introduction

   Introduces the purpose of documentation and explains why medical records matter for care delivery, communication, claims review, and related administrative needs.

2. II. General Principles of Medical Record Documentation

   Summarizes broad documentation principles that apply across medical and surgical services and describes how those principles relate to evaluation and management services.

3. III. Documentation of E/M Services

   Outlines the main components used in evaluating and documenting evaluation and management services across multiple settings and patient types.

4. A. Documentation of History

   Describes the structure of history documentation and the categories used to organize that portion of an evaluation and management record.

5. Chief Complaint (CC)

   Defines the role of the chief complaint in the record and its relationship to the encounter.

6. History of Present Illness (HPI)

   Covers the narrative structure of the present illness and the general elements used to characterize it.

7. Review of Systems (ROS)

   Describes the system-by-system review used in history documentation and the broad categories included in that review.

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

   Explains the three history areas that may be included in this portion of the record and how they vary by service type.

9. B. Documentation of Examination

   Describes the overall structure of examination documentation and the broad examination categories recognized for evaluation and management services.

10. General Multi-System Examinations

    Summarizes how multi-system examinations are organized and how documentation expectations vary by level.

11. Single Organ System Examinations

    Summarizes how single-organ-system examinations are organized and how documentation expectations differ by specialty-oriented exam type.

12. C. Documentation of the Complexity of Medical Decision Making

    Introduces the framework used to document the complexity of medical decision making and the general factors that contribute to it.

13. Number of Diagnoses or Management Options

    Covers the broad considerations involved in documenting the number of problems and management choices addressed during an encounter.

14. Amount and/or Complexity of Data to Be Reviewed

    Describes the types of supporting information and diagnostic data that may affect documentation of medical decision making.

15. Risk of Significant Complications, Morbidity, and/or Mortality

    Presents the general concept of risk assessment within evaluation and management documentation and how it relates to presenting problems and management choices.

16. Table of Risk

    Provides a broad risk framework organized by presenting problems, diagnostic procedures, and management options.

17. D. Documentation of an Encounter Dominated by Counseling or Coordination of Care

    Explains how encounters dominated by counseling or coordination of care are documented and how time is used in that context.