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The History

Created by The Lung Doctor for e-Medtools


History Components and Levels
HPI ROS PFSH Type of History
Brief N/A N/A Problem Focused

Brief Problem N/A Expanded


pertinent Problem Focused
Extended Extended Pertinent Detailed

Extended Complete Complete Comprehensive

New patient evaluations MUST have at least a Detailed History

Created by The Lung Doctor for e-Medtools


History of Present Illness
EVERY encounter MUST contain a Chief Complaint!
 Preferentially stated in patients’ words

Elements of HPI
Location
Quality Brief
Severity Contains 1-3 elements listed
Duration Extended
Timing Contains ≥ 4 elements
OR discusses 3 chronic or inactive conditions
Context
Modifying factors
Associated Signs and Symptoms

Created by The Lung Doctor for e-Medtools


Review of Systems
Constitutional Symptoms
Problem Pertinent
Eyes Documents responses to the system
Ears, Nose, Mouth, Throat directly related to the presenting
Cardiovascular problem
Respiratory
Gastrointestinal Extended
Documents positive and negative
Musculoskeletal responses to 2-9 systems related to
Integumentary (Skin, Breast) the problem
Neurological
Psychiatric Complete
Endocrine Documents all positive and negative
responses to systems related to the
Hematologic/Lymphatic presenting problem AND all other
Allergy/Immunologic systems (10 or more total)

Created by The Lung Doctor for e-Medtools


Past, Family and Social History
Past Medical History
 Illnesses, Operations, Injuries and Treatments

Family Medical History


 Include heritable diseases and those that place the patient at increased risk

Social History
 An age appropriate review of past and current activities
Pertinent
Document at least 1 item from ANY of the 3 areas
It must be directly related to the problems identified in the HPI

Complete
All initial inpatient services require a Complete PFSH
Document at least 1 item from EACH of the 3 areas
Created by The Lung Doctor for e-Medtools

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