How to Document a Patient’s Medical History

There are three types of ROS: problem pertinent, extended and complete, with 14 individual systems recognized by the E/M guidelines:

1. Constitutional symptoms (e.g., fever, weight loss);
2. Eyes;
3. Ears, nose, mouth, throat;
4. Cardiovascular;
5. Respiratory;
6. Gastrointestinal;
7. Genitourinary;
8. Musculoskeletal;
9. Integumentary (skin and/or breast);
10. Neurological;
11. Psychiatric;
12. Endocrine;
13. Hematologic/lymphatic; and
14. Allergic/immunologic.

A problem-pertinent ROS should be directly related to the problem listed in the HPI. For example, positive for pain in right toe; denies rashes, sprain, strain or fractures.

An extended ROS should relate directly to the HPI and some additional systems (2–9). For example, if there are two systems reviewed: patient denies chest pain, syncope, palpitations and shortness of breath. Patient indicates worsening unilateral pain in right toe.

Finally, a complete ROS should be directly related to a problem in the HPI, plus all additional organ systems (minimum of 10). All 10 systems must be individually documented with a positive or pertinent negative response. The remaining systems can be notated as “all other systems are negative,” if that is the case. For example, the following 10 signs and symptoms to record could include:

• Constitutional: weight stable, fatigue.
• Eyes: loss of peripheral vision.
• Ear, nose, mouth, throat: no complaints.
• Cardiovascular: denies palpitations; denies chest pain; denies calf pain, pressure, or edema.
• Respiratory: shortness of breath on exertion.
• Gastrointestinal: appetite good, denies heartburn and indigestion, no episodes of nausea. Bowel movement daily; denies constipation or loose stools.
• Urinary: denies incontinence, frequency, urgency, pain or discomfort.
• Skin: clammy, moist skin.
• Neurological: no fainting; denies numbness, tingling and tremors.
• Psychiatric: denies memory loss or depression, mood pleasant.

Past, Family and/or Social History: The last section of the history component includes the PFSH. For a new patient, all three elements must be documented, while established patients require only two of the elements for the highest level of PFSH. Providers do not have to duplicate a PFSH if there is an earlier version available on the chart. It is acceptable to review the earlier version of the PFSH and document any changes. In order to use this shortcut, you must record the date and location of the earlier version of the PFSH, but record any changes within the body of the current note.

The key purpose of complete & accurate documentation in the medical record is to foster a culture of quality & continuity of patient care.

The three areas of the PFSH for documentation include:

• Past history—experiences with illnesses, operations, injuries, and treatments;
• Family history—a review of medical events, diseases and hereditary conditions that may place the patient at risk; and
• Social history—age-appropriate review of past and current activities.

The two types of PFSH in the history component are pertinent and complete. A pertinent PFSH must have at least one area documented and be directly related to the problem in the HPI. A complete PFSH consists of two or all three areas (depending on the category of E/M service).