Give your E/M documentation a check-up: History-taking 101

Why This Topic Matters

Accurate E/M coding depends on complete history documentation, and gaps in that documentation can affect audit outcomes and reported service levels. The article helps readers recognize the broad documentation elements that should be present in pediatric encounters.

Article Sections

1. Four categories of history reviewed

   Introduces the main history components used in E/M documentation and how they fit into the broader visit assessment.

2. Chief Complaint (CC)

   Covers the purpose of the chief complaint and how it is reflected in the medical record.

3. History of Present Illness (HPI)

   Reviews the elements used to characterize the presenting problem and the general documentation expectations for this portion of history.

4. Review of Systems (ROS)

   Discusses the body systems review component, its role in the encounter, and documentation considerations that affect the history level.

5. Past, Family and Social History (PFSH)

   Summarizes the background history component and the kinds of contextual information it may address.

6. Select problem-focused, expanded, detailed or comprehensive

   Describes the overall history-level categories used in E/M documentation and the additional considerations that can affect review of the record.