E/M Tool Usage: History

The extent of history of present illness (HPI), review if systems (ROS), and past medical, family, and/or social history (PFSH) obtained and documented is dependent upon clinical judgement and the nature of the patient’s presenting problem(s).

Basic understanding on how to use an E/M tool with theses simple need to know tips.

History of Present Illness (HPI)- Description of illness or injury by the patient or person giving the information:

·        Location-where it hurts (LT leg, stomach)

·        Quality– descriptive (throbbing, productive, red)

·        Severity– level of pain (pain scale, temps to 102)

·        Duration -how long it’s been hurting/going on (5 days) (don’t mixup w/timing)

·        Timing– when it hurts (in the pm, intermittent, worse at night) (don’t mixup w/duration)

·        Context– how you got hurt/sick (falling, exposure at work/school)

·        Modifying factors– what helps or not(Motrin reduced fever, ice, heat)

·        Associated signs and symptoms– cough, fever, etc…..

Past, Family, & Social History (PFSH)

*Past History– The patient’s past experiences w/illnesses, operations, injuries, treatments, medications & allergies.

*Family History-review medical events in the patient’s family including diseases which are hereditary or put the patient at risk.

*Social History-an age appropriate review of past and current activities(drink,smoke,….)

If one column contains three circles, draw a line down that column to the bottom row to identify the type of history.

If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history.

After completing this table which classifies the history, circle the type of history within the appropriate grid below.

	PROBLEM FOCUSED	EXP.PROB. FOCUSED	DETAILED	COMPREHENSIVE
HPI: Status of chronic conditions: 1 condition, 2 condition, 3 condition OR		Status of 1-2 chronic conditions		Status of 3 chronic conditions
HPI: (history of present illness) elements: _Location, _Severity, _Timing, _Modifying factors, _Quality, _Duration, _Context, _Associated signs and symptoms	Brief (1-3)	Brief (1-3)	Extended (4 or more)	Extended (4 or more)
ROS (review of systems): _Constitutional (wt loss, etc), _Eyes, _Ears, nose, mouth, throat, _Gastrointestinal (GI), _Genitourinary (GU), _Integumentary (skin, breast), _Endocrinology, _Hem/lymph, _Card/vasc, _Musculo, _Neuro, _All/immuno, _Resp, _Psych, _All others negative	None	Pertinent to Problem (1 system)	Extended (2-9 systems)	* Complete (10 or more) Some systems + statement “all others negative”
PFSH (past medical, family, social history) areas: _Past history ( the patient’s past experiences with illnesses, operation, injuries and treatments) _Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk) _Social history (an age appropriate review of past and current activities)	None	None	Pertinent (1 history area)	** Complete (2 or 3 history areas)

Example part I A Patient with a history of CHF who presents with shortness of breath CC : “ Shortness of breath.” HPI: Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks(duration) ago. The shortness of breath may occur at rest or with exertion(context). The timing is described as intermittent(timing). His breathing is worse when laying flat(modifying factors). He has noticed his shortness of breath is often associated with worsening lower extremity swelling(assoc signs & symptoms). He states he has a history of heart disease, but had a negative nuclear stress test approximately one year ago. Medications Atenolol 25 mg PO QD Glyburide 5 mg PO BID Lisinopril 10 mg PO BID Atorvastatin 20 mg PO QD PMH: per HPI, plus osteoarthritis and dyslipidemia FH: Mother died in her 80s of “old age”; father at age 72 of pneumonia.  The patient has three grown children in good health.   SH: The patient has been married for 45 years.  He denies tobacco or alcohol abuse and continues to drive himself around. ROS: Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising.  HPI has 5 elements: duration, context, timing, modifying factors, and associated s&s ROS-Complete which it states complete PFSH-Complete due to talking about histories HISTORY -Comprehensive