Appendix A_EM Guidelines / 1995 EM Guidelines / A. Documentation of History

Why This Topic Matters

Accurate history documentation is a core part of E&M coding and audit review. Understanding the framework helps readers assess whether a record supports the intended level of service without relying on missing or incomplete history elements.

Article Sections

1. Documentation of History

   Introduces the history framework used in 1995 E&M guidance and outlines the major history types and core elements involved in documentation.

2. Documentation Guideline

   Summarizes general guidance on where history elements may appear in the record, how previously obtained information may be handled, and what to do when history cannot be obtained.

3. Chief Complaint (CC)

   Defines the chief complaint component and explains its role in the encounter documentation.

4. History of Present Illness (HPI)

   Describes the HPI component, the kinds of information it includes, and the distinction between brief and extended histories.

5. Review of Systems (ROS)

   Explains the ROS component, the body systems recognized for review, and the general levels of ROS documentation.

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

   Covers the PFSH component, the three areas included in that review, and the general expectations for pertinent and complete history documentation.