HISTORY
Patient Name:______________________________
 New Patient
ID#_________________________
 Established Patient
 Consultation
PRIMARY CARE PHYSICIAN:_____________________________
Date:_____/_______/_______
 Report Sent_____/_____/______
WHO SENT PATIENT:____________________________
OTHER PHYSICIAN(S):_________________________________
CHIEF COMPLAINT: (Required for all visits)
CURRENT MEDS:  None
_________________________________________________
__________________________________________________
_________________________________________________
__________________________________________________
LAST PAP:_____/______/______
ALLERGIES:  None
LAST MAMMOGRAM:______/_____/______
__________________________________________________
LAST COLORECTAL SCREENING:______/______/______
__________________________________________________
HISTORY OF PRESENT ILLNESS (HPI): Brief = 1-3 elements
 New Problem
Extended = 4+ elements or status of 3+ chronic/inactive conditions
 Existing Problem
Location; Quality; Severity; Duration; Timing; Context; Modifying Factors; Assoc. Signs & Symptoms
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
 Non-Contributory
 No Interval Change since _____/_____/_____
Mother:  Living  Deceased -- Cause______________ Father:  Living  Deceased -- Cause__________________
Sibling: Number Living____ Number Deceased_____
Cause(s)___________________________________________
 Diabetes______________
 Heart Disease___________________  Hyperlipidemia__________________
FAMILY HISTORY (FH):
 Cancer________________
 Hypertension___________________
 Other________________________________________________________________________________________
PAST HISTORY (PH):  Non-Contributory
 No Interval Change since ______/______/______
Surgeries:______________________________________________________________________________________________
Illness(es):_____________________________________________________________________________________________
Injuries:_______________________________________________________________________________________________
Immunizations:__________________________________________________________________________________________
SOCIAL HISTORY (SH):
 Non-Contributory
 No Interval Change since ______/______/_______
 No
Yes_________________________________________________________________________
Alcohol/Drugs Use:  No
Yes_________________________________________________________________________
Domestic Violence:  No
Yes_________________________________________________________________________
Tobacco Use:
Seat Belt Use
 No
Yes
 Diet Discussed____________________
Reg. Exercise: No Yes ________________________________________
 Other_______________________________________________________________________________________________
Pertinent PFSH=
1 specific item from either Past, Family or Social Hx
Complete PFSH=
New patient, 1 specific item from each Hx type (Past, Family or Social Hx);
Established patient, 1 specific item from 2 of the 3 Hx type (Past, Family or Social Hx)
HISTORY (CONTINUED)
REVIEW OF SYSTEMS (ROS)
Problem Pertinent ROS = Pos. & Pert. Neg responses related to problem
Extended ROS =
Pos. & Pert. Neg. responses for 2-9 systems
Complete ROS =
Pos. & Pert. Neg. responses for at least 10 systems
 No Changes Since_______/__________/________
1. Constitutional
 Negative
 Wt loss
 Wt gain
 Fever
 Fatigue
 Other____________________________________________________________
 Negative
2. Eyes
 Vision chg  Glasses/contacts
 Other____________________________________________________________
3. ENT/Mouth
 Negative
 Ulcers
 Sinusitis
 Tinnitus  Headache
 Other____________________________________________________________
4. Cardiovascular  Negative
 Orthopnea  Chest pain  DOE
 Edema  Palpitation
 Other____________________________________________________________
5. Respiratory
 Negative
 Wheezing
 Hemoptysis  SOB
 Cough
 Other____________________________________________________________
6. Gastrointestinal  Negative
 Diarrhea
 Bldy stool
 N/V
 Const.
 Flatulence
 Pain
 Other____________________________________________________________
7. Genitourinary
 Negative
Hematuria
 Dysuria
 Urgncy  Frqncy  Incomp. emptying
 Incontinent  Abn Bldng
 Dyspareunia
 Other____________________________________________________________
8. Musculoskeletal  Negative
 Mscl wkness
 Other____________________________________________________________
9. Skin/breast
 Negative
 Mastalgia
 Discharge
 Masses  Rash
 Ulcers
 Other____________________________________________________________
10. Neurological
 Negative
 Syncope
 Seizures
 Nmbnss  Trouble walking
 Other____________________________________________________________
11. Psychiatric
 Negative
 Depression  Crying
 Other
12. Endocrine
 Negative
_________________________________________________________
 Diabetes
 Hypothyroid  Hyperthyroid
 Hot flashes
 Other____________________________________________________________
13. Hemat/Lymph  Negative
 Bruises
 Other
 Bleeding
 Adenopathy
_________________________________________________________
14. Allergic/Immuno (see first page)
TOTAL NUMBER SYSTEMS REVIEWED:_____________________
CC
HPI
ROS
PFSH
Level of History
Required
Required
Brief
Brief
N/A
Problem Pertinent
N/A
N/A
Required
Extended
Extended
Pertinent
Problem Focused
Expanded Problem Focused
Detailed
Required
Extended
Complete
Complete
Comprehensive
PHYSICAL EXAMINATION
ORGAN SYSTEMS
CONSTITUTIONAL (Vital
Signs, General Appearance
Vital signs Ht___________ Wt___________ BP______________ T___________ P_________ R_______
General appearance:________________________________________________________________________________
EYES:_________________________________________________________________________________________________
______________________________________________________________________________________________________
EARS, NOSE, MOUTH, THROAT:_______________________________________________________________________________
______________________________________________________________________________________________________
CARDIOVASCULAR:________________________________________________________________________________________
______________________________________________________________________________________________________
RESPIRATORY:___________________________________________________________________________________________
______________________________________________________________________________________________________
GASTROINTESTINAL:______________________________________________________________________________________
______________________________________________________________________________________________________
GENITOURINARY:_________________________________________________________________________________________
______________________________________________________________________________________________________
SKIN:__________________________________________________________________________________________________
______________________________________________________________________________________________________
MUSCULOSKELETAL:______________________________________________________________________________________
_
______________________________________________________________________________________________________
NEUROLOGICAL:__________________________________________________________________________________________
______________________________________________________________________________________________________
HEMATOLOGIC/LYMPHATIC:__________________________________________________________________________________
______________________________________________________________________________________________________
PSYCHIATRIC:____________________________________________________________________________________________
______________________________________________________________________________________________________
BODY AREAS
Head/face:__________________________________________________________________________________________
Neck:______________________________________________________________________________________________
Chest/Breasts/Axillae:_________________________________________________________________________________
Abdomen:__________________________________________________________________________________________
Genitalia/Groin/Buttocks:______________________________________________________________________________
Back/Spine:_________________________________________________________________________________________
Each Extremity:
Content and Documentation Requirements
For each level of examination, the following must be documented in the chart:
 Specific abnormal and relevant negative findings for affected or symptomatic body area(s)/organ system(s)
 Abnormal or unexpected findings of unaffected or asymptomatic body area(s)/organ system(s)
 “Normal” or “negative” is only sufficient for unaffected area(s) or asymptomatic organ system(s)
Level of Exam
Perform and Document
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Limited exam of one body area or organ system
Limited exam of the affected body area or organ system plus any other symptomatic or
related organ system(s) - commonly interpreted by HCFA auditors to mean 2-4 systems
total.
Extended exam of the affected body area(s) and other symptomatic or related organ
system(s) - commonly interpreted by HCFA auditors to mean 5-7 systems total.
General Multisystem: Documentation of 8 or more findings about the 12 organ systems
Single Organ System: Not formally defined and left up to the discretion of the auditor, but CPTdefined as a complete exam of a single organ system
MEDICAL DECISION MAKING
AMOUNT AND COMPLEXITY OF DATA REVIEWED:
Test(s) ordered:
 Laboratory_________________________________________________________________________________________
 Radiology/Ultrasound________________________________________________________________________________
Review of Records:
 Previous Test results:____________________________________________________________________________
 Discussion of test results with other physician_______________________________________________________
 Old records reviewed:____________________________________________________________________________
 History obtained from other source:________________________________________________________________
Minimal/None = 1 from above, Limited = 2 from above, Moderate = 3 from above, Extensive = 4+ from above
DIAGNOSES/MANAGEMENT OPTIONS:
 Minimal = Minor problem
 Established Problem
 New Problem
 Limited = Established problem, stable/improved
 Multiple = Established problem, uncertain status; New problem, stable  Extensive = New problem uncertain status
ASSESSMENT AND PLAN:______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
RISK OF COMPLICATIONS AND/OR MORBIDITY/MORTALITY FROM DIAGNOSES, DIAGNOSTIC PROCEDURES AND MANAGEMENT
CHOICES:
Minimal (eg, Cold, Aches & pains, insect bite)
Low (eg, Cystitis, vaginitis, minor surgery w/no risk factors, OTC meds)
Moderate (eg Breast mass, irreg. bleeding, headaches, biopsy, minor surgery w/risk factors, Rx drug management)
High (eg, Pelvic pain, rectal bleeding, Multiple complaints, Major surgery planned, Chemotherapy,)
PATIENT COUNSELED RE:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Minutes Counseled__________________ Total Encounter Time______________________
Signature____________________________________________________Date______/_____/_____
2 of the 3 elements must be met or exceeded to qualify for a given type of medical decision making
Amt/Complexity Data
Diagnoses/ Mgt
Risk of Complications
Type of Decision-Making
Options
Minimal/ None
Minimal
Minimal
Straight-forward
Limited
Limited
Low
Low Complexity
Moderate
Multiple
Moderate
Moderate Complexity
Extensive
Extensive
High
High Complexity