HISTORY

Chief Complaint: Description of the reason for the encounter (i.e. follow-up evaluation of obesity)
History of Present Illness (HPI): Details describing the chief complaint
1-3 elements = brief 4 elements = extended New Pt 99201 99202 99203 99204 99205
Location: Site of the problem - body area, right/left, bilateral, fixed, localized 1-3 1-3 4 4 4
Quality: Characteristics of the problem - acute/chronic, sharp/dull, worsening/improving,color Est Pt 99211 99212 99213 99214 99215
Severity: Severity of the problem - on a scale of 1-10, stage of disease (i.e. morbidly obese), compared to . . n/a 1-3 1-3 1-3 4
Duration: Length of time problem has occurred - since 2011, started 2 years ago Consult 99241 99242 99243 99244 99245
Timing: Onset and progression of problem - time of day it occurs, recurrent, continuous 1-3 1-3 4 4 4
Context: What patient is doing when problem occurs - while sleeping, after exercise, stress, fell down stairs
Modifying Factors: What patient has done to help/worsen problem - took aspirin, applied ice, better after rest, exercises twice
a week
Associated Signs/Symptoms: Other symptoms related to problem, generalized symptoms, exercised induced asthma
Review of Systems (ROS)
1 system = problem pertinent 2-9 systems = extended 10+ systems = complete New Pt 99201 99202 99203 99204 99205
Unable to Obtain: Patient in a coma, severely agitated, unable to communicate none 1 2-9 10 10
Constitutional Symptoms: Weight loss/gain, fatigue, fever/chills, sweats, headache, appetite Est Pt 99211 99212 99213 99214 99215
Allergic/Immunologic: Drug/food/pet allergies, hayfever, HIV/AIDS, immunization status n/a none none 1 2-9
Integumentary: Color changes, itch, rash, sores, hives, moles, alopecia, breast pain/discharge/lumps Consult 99241 99242 99243 99244 99245
Eyes: Vision changes, blurriness, dryness, pain, cataracts, glasses/contacts, photophobia none 1 2-9 10 10
ENT: Tinnitus, hearing, discharge, pain, obstruction, sinusitis, PND, epistaxis, sore throat, dysphagia, canker sores
Cardiovascular: Chest pain upon exertion, murmurs, angina, HTN, MI, palpitations, thrombosis, PVD, DVT,
Respiratory: Dyspnea, cough, infection, sputum, wheezing, SOB, hemoptysis, congestion
Musculoskeletal: Pain, weakness, cramps, joint pain, swelling, arthritis, strain/sprain/fracture, scoliosis, atrophy
Gastrointestinal: Bloating, nausea, vomiting, heartburn, diarrhea, constipation, abdominal pain, hematemesis
Neurological: Syncope, seizures, vertigo, coordination, memory loss, paralysis, tremors, blackouts, ataxia, numbness
Genitourinary: Dysuria, hematuria, frequency, burning, urgency, renal stones, STD, infertility, menses
Endocrine: diabetes, excessive hunger/thirst, goiter, puberty onset, infertility, hirsutism
Hematologic/Lymphatic: Bleeding disorders, anemia, tenderness of lymph nodes
Psychiatric: Depression, anxiety, hallucinations, suicidal ideation, tension, mood changes, substance abuse, addictions New Pt 99201 99202 99203 99204 99205
Past, Family, Social History (PFSH) none none 1 3 3
1 of 3 elements = pertinent 2 (or 3) of 3 elements = complete Est Pt 99211 99212 99213 99214 99215
Past Medical History : Prior illnesses, hospitalizations, surgeries, injuries,current meds n/a none none none none
Family History: Similar illness in family, health status/cause of death of relatives Consult 99241 99242 99243 99244 99245
Social History: Personal status, habits, employment, sexual history, use of alcohol/tobacco none none 1 3 3
EXAM
1 system/area = problem focused (pf) limited syst/area + other related systems = expanded (exp)
extended system/area + other related systems = detailed (det)
general multi-syst (8+ systems) or complete single system = comprehensive (comp)
Organ Systems New Pt 99201 99202 99203 99204 99205
Constitutional (incl. vitals): General appearance, alert, intubated, sedated pf exp det comp comp
Integumentary: Bruising, rash, exam of incision site Est Pt 99211 99212 99213 99214 99215
Eyes: PERRLA, EOMI, acuity exam n/a pf exp det comp
ENT/Mouth: MM, O/P, TM, teeth Consult 99241 99242 99243 99244 99245
Cardiovascular: RRR, murmur, gallops, S 1 , S 2, cyanosis, edema pf exp det comp comp
Respiratory: Lungs CTA, wheezes, rales; breath sounds
Musculoskeletal: Motor/strength, ROM, joint exam, clubbing
Gastrointestinal: Bowel sounds, HSM, rectal exam
Neurological: Reflexes, CNs, tremors, unresponsive
Genitourinary: Pelvic exam, kidneys
Hematologic/Lymphatic: Lymphadenopathy
Psychiatric: Orientation, mental status, judgement/insight
Body Areas
Head/Face: NCAT, sinus tenderness
Neck: Supple, JVD, thyromegaly
Chest: Breast exam, ARM
Extremity: Cyanosis, clubbing, edema
Abdomen: Soft, tenderness, distention, rebound, guarding
Genitilia/Groin/Buttock: External genital exam
Back/Spine: CVAT, back tenderness
MEDICAL DECISION MAKING
Minimal dx/tx options, minimal amount/ complexity of data, minimal risk = straightforward (sf)
Limited dx/tx options, limited amount/complexity of data, low risk = low complexity (low) New Pt 99201 99202 99203 99204 99205
Multiple dx/tx options, multiple amount/complexity of data, moderate risk = moderate complexity (mod) sf sf low mod high
Extensive dx/tx options, extensive amount/complexity of data, high risk = high complexity (high) Est Pt 99211 99212 99213 99214 99215
n/a sf low mod high
Consult 99241 99242 99243 99244 99245
sf low mod mod/hi high
Reproduced with permission for ICAAP's Improving Quality of Care for Prevention and Treatment of Childhood Obesity project