HISTORY – 1997 GUIDELINES

Patient ID#___________________________ Date: ________/_______/________

Name:________________________________
 New Patient  Established Patient  Consultation  Report Sent ________/_______/________
PRIMARY CARE PHYSICIAN:________________________________ WHO SENT
PATIENT:_____________________________________________
OTHER PHYSICIAN(S):____________________________________

CHIEF COMPLAINT: (Required for all visits) CURRENT MEDS:  None

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LAST PAP: ________/________/_______ ALLERGIES:  None
LAST COLORECTAL _______/________/________ ___________________________________________________
SCREENING:
_______/________/________ ___________________________________________________
LAST MAMMOGRAM:

HISTORY OF PRESENT ILLNESS (HPI) Brief = 1-3 elements Extended = 4+ elements or 3+ chronic/inactive conditions
 New Problem  Existing Problem
Elements: Location; Quality; Severity; Duration; Timing; Context; Modifying Factors; Associated Signs & Symptoms
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PAST, FAMILY, SOCIAL HISTORY (PFSH)
Pertinent PFSH= 1 specific item from either Past, Family or Social History
Complete PFSH= New patient: 1 specific item from past, family and social history
Established patient: 1 specific item from 2 of the 3 history areas (past, family or social history)
FAMILY HISTORY (FH):  Non-Contributory  No Interval Change since __________/__________/________
Mother:  Living  Deceased Cause__________ Father:  Living  Deceased Cause_________________
Siblings: Number Living Number Deceased Cause(s)
 Diabetes____________  Heart Disease______________________  Hyperlipidemia______________________________
 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 __________/__________/________
Tobacco Use:  No Yes_____________________________________________________________________________
Alcohol/Drugs Use  No Yes_____________________________________________________________________________
Domestic Violence:  No Yes_____________________________________________________________________________

Seat Belt Use  No Yes_____________________________________________________________________________

 Diet Discussed_________________________ Reg. Exercise:  No  Yes _______________________________________

 Other____________________________________________________________________________________________________
 history – 1997 Guidelines (continued)
REVIEW OF SYSTEMS (ROS)
Problem Pertinent ROS = Positive & pertinent negative responses related to problem
Extended ROS = Positive & pertinent negative responses for 2-9 systems
Complete ROS = Positive & pertinent negative responses for at least 10 systems
 No Changes Since_______/__________/________
1. Constitutional  Negative  Weight loss  Weight gain  Fever  Fatigue
 Other________________________________________________________________________________
2. Eyes  Negative  Vision change  Glasses/contacts
 Other________________________________________________________________________________

Other____________
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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  Bloody stool  N/V  Constipation
 Flatulence  Pain  Other_________________________________________________
7. Genitourinary  Negative Hematuria  Dysuria  Urgency  Frequency
 Incomplete emptying  Incontinent  Abnl Bleeding  Dyspareunia
 Other________________________________________________________________________________
8. Musculoskeletal  Negative  Muscle weakness

 Other_______________________________________________________________________________
9. Skin/breast  Negative  Mastalgia  Discharge  Masses  Rash
 Ulcers  Other_________________________________________________________________
10. Neurological  Negative  Syncope  Seizures  Numbness
 Trouble walking  Other_________________________________________________
11. Psychiatric  Negative  Depression  Crying
 Other________________________________________________________________________________
12. Endocrine  Negative  Diabetes  Hypothyroid  Hyperthyroid  Hot flashes
 Other________________________________________________________________________________
13. Hemat/Lymph  Negative  Bruises  Bleeding  Adenopathy
 Other________________________________________________________________________________
14. Allergic/Immuno (see first page)

LEVEL OF HISTORY REQUIREMENTS FOR LEVELS OF HISTORY

CC HPI ROS PFSH CC
Problem Focused Required Brief N/A N/A Required
Expanded Problem Required Brief Problem Pertinent N/A Required
Focused
Detailed Required Extended Extended Pertinent Required
Comprehensive Required Extended Complete Complete Required
 1997-Female Genitourinary Examination
CONSTITUTIONAL (Comprehensive exam requires at least 3 vital signs plus general appearance)
 ANY 3 VITAL SIGNS Ht W BP T P R
t
 General appearance (Note all that apply)
 Well-developed  Other
 Well-nourished  Other
 Normal habitus  Obese  Other
 No deformities  Other
 Well-groomed  Other
NECK
 Neck  Normal  Abnormal
 Thyroid  Normal  Abnormal
RESPIRATORY
 Respiratory effort  Normal  Abnormal
 Ausculation of lungs  Normal  Abnormal
CARDIOVASCULAR
 Ausculation of heart  Normal  Abnormal
 Peripheral vascular  Normal  Abnormal
GASTROINTESTINAL (Comprehensive exam requires all bulleted elements)
 Abdomen  Normal  Abnormal
 Hernia  Normal  Abnormal
 Liver/spleen
Liver  Normal  Abnormal
Spleen  Normal  Abnormal
 Stool guaiac if indicated
LYMPHATIC
 Palpation of nodes (Note all that apply)
Neck  Normal  Abnormal
Axilla  Normal  Abnormal
Groin  Normal  Abnormal
Other site  Normal  Abnormal
 SKIN
Inspect/palpate  Normal  Abnormal
NEUROLOGICAL/PSYCHIATRIC
 Orientation
 Time  Place  Person Comments
 Mood and Affect
 Normal  Depressed  Anxious  Agitated  Other

GYNECOLOGIC (Comprehensive exam requires at least 7 bulleted elements)

 Breasts  Normal  Abnormal
 Rectal  Normal  Abnormal
 External genitalia  Normal  Abnormal
 Urethral meatus  Normal  Abnormal
 Bladder  Normal  Abnormal
 Vagina/pelvic support  Normal  Abnormal
 Cervix  Normal  Abnormal
 Uterus  Normal  Abnormal
 Adnexa/parametria  Normal  Abnormal
 Anus/perineum  Normal  Abnormal
TOTAL NUMBER OF ● ELEMENTS EXAMINED

LEVEL OF EXAM PERFORM AND DOCUMENT

Problem Focused One to five elements identified by a bullet
Expanded Problem Focused At least six elements identified by a bullet
Detailed At least twelve elements identified by a bullet
Comprehensive Bullets as indicated in each shaded box plus at least one element in each unshaded box
 MEDICAL DECISION MAKING-1997 GUIDELINES
AMOUNT AND COMPLEXITY OF DATA REVIEWED

Minimal/None = 1 from below Limited = 2 from below Moderate = 3 from below Extensive = 4+ from below
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:

DIAGNOSES/MANAGEMENT OPTIONS:  Established Problem  New Problem

 Minimal = Minor problem  Limited = Established problem, stable/improved
 Multiple = Established problem,  Extensive = New problem, uncertain status
uncertain status; New problem, stable
ASSESSMENT AND PLAN:_________________________________________________________________________

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RISK OF COMPLICATIONS AND/OR MORBIDITY/MORTALITY FROM DIAGNOSES, DX 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:

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Minutes Counseled_________________________ Total Encounter Time_______________________________

Signature ____________________________ Date_________/__________/___________

REQUIREMENTS FOR LEVELS OF MEDICAL DECISION MAKING

2 of the 3 elements must be met or exceeded to qualify for a given type of medical decision making
Type of Medical Decision Making Amt/Complexity Data Diagnoses/ Mgt Options Risk of Complications
Straightforward Minimal/ None Minimal Minimal
Low Complexity Limited Limited Low
Moderate Complexity Moderate Multiple Moderate
High Complexity Extensive Extensive High