When dissecting the history component these are required components to be documented:
• "Chief Complaint" (CC)
• "History of Presenting Illness (HPI) OR "Chronic Condition Status" (CCS)
• "Review of Systems" (ROS/ROI
• the patients "Past", "Family", and "Social" history (PFSH)
The Chief Complaint -
Definition: A patient’s chief complaint or purpose for a visit.
The purpose for the medical visit is clearly stated by the patient, and is recorded by the provider of care. The documentation supports that the patient’s perceived needs/expectations and should be addressed during the encounter.
The "History of Presenting Illness (HPI)
Definition: an account obtained during the interview with the patient of the onset, duration, and character of the present illness, as well as of any acts or factors that aggravate or ameliorate the symptoms. The patient is asked what he or she considers to be the cause of the symptoms and whether a similar condition has occurred in the past
OR The "Chronic Condition Status" (CCS)
Definition: a chronic disease is a disease that is long-lasting or recurrent. The term chronic describes the course of the disease, or its rate of onset and development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in between.
The Review of Systems" (ROS)
Definition: In a health history, a ROS is a system-by-system review of the body functions. The ROS is begun during the initial interview with the patient and completed during the physical examination. As physical findings prompt further questions, providers of care are to outline the systems reviewed and notate if the signs and symptoms are normal, abnormal, or anecdotal.
The "History" of the patient: (PFSH)
Past(Personal) Medical History
A narrative or record of past events and circumstances that are or may be relevant to a patients current state of health. Informally, an account of past diseases, injuries, treatments, and other strictly medical facts. More formally, a comprehensive statement of facts pertaining to past and present health gathered, ideally from the patient, by directed questioning and organized within the medical documentation or chart. This can also be noted as a review of the patients past experiences, including illnesses, injuries, treatments, allergies etc.
Past Family History
The family structure and relationships within the family, including information about diseases in family members. The family history provides a ready view of problems or illnesses within the family and inheritance patterns. Study of a trait or disease(s) begins with the affected person and is considered pertinent as the relatives are described. (ie father, mother, siblings, grandparents, aunts, uncles, cousins) At least 3 generations are usually included. Illnesses, hospitalizations, causes of death, miscarriages, abortions, congenital anomalies, and any other unusual features are recorded.
Social History (SH):
A review of the patients past experiences, including illnesses, injuries, treatments, allergies, and may include marital status, past and present occupations, travel, hobbies, stresses, diet, habits, and use of tobacco, alcohol, or drugs
In compiling the analysis of the "historical" relevance of the patients history to their current medically presenting illness (HPI) the provider of care will need to carefully consider all facts that are pertinent.
When Auditing the documented history, you cannot "double dip" so to speak, each element has to stand on its own merits.
In identifying the amount of history noted in the record, do not confuse the "review of systems" with "past history" or with the chronic condition status (CCS)
Consider how to put this together within your audit tool to determine the correct level of history that the patient had presented for the provider of care.
These histories do not need to be recorded or re-recorded at every visit, however, the physician or provider DOES need to review the history or historical relevance to the presenting illness and document that they DID REVIEW THE PREVIOUS HISTORY NOTED IN THE CHART. If the patient does reveal more, or un-documented ares of history, the provider should update the record with the additional information.
The Audit Tool: