Answer_Book / Documentation_Guidelines_for_EM_Services / a._documentation_of_history95

Why This Topic Matters

Accurate history documentation is a core part of E/M code support and medical record compliance. Understanding the guideline framework helps users evaluate whether documentation is complete and appropriately organized for review.

Article Sections

1. Overview of history levels and elements

   Introduces the types of history used in E/M services and the standard elements that make up a history. It also explains the general relationship between the elements and the history levels.

2. Documentation guidelines

   Covers general guidance on where history information may appear in the record, how previously obtained information may be handled, and what is expected when history cannot be obtained.

3. Definitions and specific documentation guidelines for history elements

   Identifies the sections that provide more detailed guidance for individual history elements.

4. Chief Complaint (CC)

   Introduces the section focused on the chief complaint element of history.

5. History of Present Illness (HPI)

   Introduces the section focused on the history of present illness element of history.

6. Review of Systems (ROS)

   Introduces the section focused on the review of systems element of history.