Documentation of History and Physical for a level 3 admission

In order to get paid, we have to properly document our patient encounter.

Three Key Components of documentation are History, Physical Exam and Medical Decision making.


History ExamMedical Decision Making
Problem focusedProblem focusedMinimal Complex
Expanded problem focusedExpanded problem focusedLow Complex
DetailedDetailedModerate Complex
ComprehensiveComprehensiveHigh Complex

There are Seven Basic Components:

1.Patient History 2. Physical Examination 3. Medical Decision Making 4. Counseling 5. Coordination of care, 6. The nature of the patient’s presenting problem (i.e., the reason for the visit) 7. Time


Problem Focused:

1 – 3 elements of HPI*

Status of 1 – 2 chronic medical problems**

No ROS or No PMFSH needed.

Expanded Problem Focused

1 – 3 elements of HPI*

Status of 1 – 2 chronic medical problems**

1 ROS Problem


4 elements of HPI*

Status of 3 chronic medical problems**  

2 – 9 ROS  One pertinent PFSH  (PFSH NOT required for hospital progress notes)


4 elements of HPI*

Status of 3 chronic medical problems**

10 system ROS Complete PFSH (all 3)

*(1995)           ** (1997)


Chief Complaint: in chronological order if more than one

History of present illness: Mention four elements of the history of the present illness

For example, if pain is the complaint, mention 4 of the following.

Location, Intensity, Quality, Associated features, Radiation, Aggravating and Alleviating factors.

If you can’t obtain history, mention the reason like in demented patients or intubated patient or altered mental status

Document if you talked to family members or friends to get more history.

Past Medical History: Do not mention ‘Non-Contributory or not on file’

Family History: Do not mention ‘Non-Contributory’

Social History: Smoking, Alcohol, Drugs



Review of Systems: obtained by a questionnaire or by ancillary staff, Previous ROS obtained by YOU can be ‘recycled’ but update information and note the date and location of the ROS

A review of at least 10 systems should be mentioned. You don’t have to say all these written below. Just mention positive findings and say “All other systems are reviewed and are negative.”

Constitutional: fever, chills, night sweats, weight change, fatigue, malaise, nutrition, grooming

Eyes: vision, pain, discharge, photophobia

Ears/Nose/Throat: hearing, tinnitus, dizziness, pain, discharge, smell, hoarseness, nose bleeds, lesions

Cardiovascular: Palpitation, chest pain, shortness of breath, PND, orthopnea, syncope, varicosities, edema

Respiratory: asthma, dyspnea, cough/sputum, hemoptysis, TB skin test status

Gastrointestinal: dysphagia, anorexia, nausea, vomiting, hematemesis, diarrhea, constipation, melena, rectal bleeding, change in bowel habits, hemorrhoids, jaundice, abdominal pain

Genitourinary: dysuria, hematuria, frequency, polyuria, urgency, hesitancy, incontinence, renal stones, nocturia

Male Reproductive: penile discharge, STD history, testicular pain or mass

Female Reproductive: postmenopausal symptoms, abnormal bleeding, STD history

Musculoskeletal: joint pain, edema, redness, stiffness, deformity, muscle pain, tenderness, atrophy

Neurological: headache, syncope, vertigo, seizures, loss of vision, diplopia, paresthesia, weakness in any limbs, tremor, ataxia, memory loss

Skin: itching, rash, lump and bumps, hair and/or nail change, de/pigmentation

Endocrine: excessive thirst, sweating, dizziness

Hematologic/Lymphatic: bruising, cyanosis, lymphadenopathy, petechiae, purpura

Psychiatric: stress, insomnia, previous psychiatric illness, hallucinations

If any part of history cannot be obtained there must be a notation as to why (such as the patient’s condition – “Ex: unable to obtain as patient intubated”)




HEENT: Normocephalic, Icterus, pallor, mucosa, lymphadenopathy, pupils, extra ocular movements, oral exam

Chest: Heart sounds, murmurs,

Lungs: Breath sounds, accessory muscles, tenderness

Abdomen: scars, bowel sounds, tenderness, organomegaly, distension, ascites, masses, rectal exam


Extremities: edema, varicose veins, ulcers, pulses, scars, tenderness, clubbing, petechiae, gangrene

Neurologic: orientation, Level of consciousness, memory, speech, cranial nerves, deep tendon reflexes, strength, tone, & cerebral function, Sensation, Cerebellar signs, Gait, movements

Musculoskeletal: Inspection/palpation, Range of Motion, Stability, Muscle Strength & Tone

Skin: rash, Induration, swelling, ulceration

Psychiatric: affect, depression, anxiety, agitation

For Physical Exam: stating NORMAL/NEGATIVE in a system is OK but if there is an Abnormal finding, it MUST BE DESCRIBED


Mention that you reviewed EKG and it shows….

Same with imaging, reviewed chest x ray and it showed…. (if you actually did.)

Be an “I” specialist – Take credit for what you did.  “I personally reviewed the following lab work and per my interpretation– “I’ve discussed the findings with Radiologist” OR Cardiologist, etc. — “I requested for outside Medical records — “I reviewed the old records and it shows in summary

Assessment and Plan

Medical Decision Making: Most important key component- reflects the actual cognitive labor required for a given patient encounter. E&M guidelines use three dimensions to quantify medical decision making 1) Nature and number of problems or diagnosis 2) Extent of data reviewed 3) Risk to the patient

Explain the plan for each diagnosis.

Mention IV medications including IV fluids, antibiotics, pain medications, etc.

Mention about DVT prophylaxis.

List EVERY problem addressed (even if you just review the medications) as it helps portray the complexity, mortality, morbidity and risks of medical decisions – Remember CCs and MCCs for DRGs built (E/O ratio ~ 1)

If not sure about exact diagnosis, can state PROBABLE/Suspected, RULE OUT, etc. but should later clarify if listed diagnoses are no longer suspected or confirmed – Also remember 5Ss of success (Side, Status, Specific site, suggest secondary to, Scores and scales makes you smart)

If it is not POA [Present on Admission] – It is HAC [Hospital Acquired Condition]

Expected mortality should be equal to Observed mortality – it is in your hands (documentation). Observed mortality – actual inpatient deaths.  Expected mortality – those inpatients who are expected to die during the hospitalization based on the clinical documentation in the medical record.

Remember 5S – Side, Status, Specific Site, suggest secondary to, Look Smart (scales and scores for Risk

Goal is to write shortest note possible (Quality over the quantity).

Risk is quantitative, use the E/M tables to get familiar with it.

Don’t add problems or data points to beef up MDM, Risk is the Key.

History and Exam are comprehensive at admission.

Principal Diagnosis: That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.  Must be present on admission (POA).

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