By Alice Anne Andress

Published July 2008

The importance of the history and physical examination in physician practice can hardly be overstated. The service rendered to the patient must be conveyed to those who pay for physician services. Document a solid history and physical and the physician will be paid for his/her service. Documenting incorrectly will cost the physician in time spent clarifying and explaining, or possibly having the claim denied.

Physicians have always been devoted to the practice of medicine and have not been attuned to documentation requirements that generate equivalent billing codes, and ultimately, reimbursement for services. Learning to document for payment must be done ethically, efficiently and legitimately.

Whether the history and physical are restricted to an area of a specific problem, such as a sprained ankle, or are performed on a more comprehensive scale, a permanent record must contain documentation to support those services. This documentation may be either in printed or electronic form. The documentation of the history and physical serves two purposes; it preserves the information from the physician and supports his or her memory, and it provides helpful information for others as continuity of patient care.

The result of the history and physical is the diagnosis of the patient. Diagnosis and disease are often used interchangeably. Diagnosis is the process of analyzing, identifying, or explaining a disease. For example, "Her diagnosis is peptic ulcer disease." A disease is a concept that we use in health care to explain a patient’s complaints and body malfunctions. Physicians use these concepts to streamline their thinking about the patient’s illness. The concern is not with how the history and physical are performed, but how they are documented in the medical record. This is of importance because it is a driving force for the selection of codes for billing.

The report of the history and physical is both subjective and objective. The history portion of the patient encounter includes documentation of patient signs and symptoms, which are obtained through careful questioning by the physician as to the details of the reason for the visit, the history of present illness, the review of symptoms, and the past, family and social history which may impact the patient’s condition. The physical examination is objective in nature and is comprised of the physical findings of the physician.

Each line of the history and physical contains physician interpretation, inference and findings, and are documented in several different ways. The language a physician uses contains many recurring phrases and terms, often based on their specialty. Some of this language is medical terminology and some is institutional or personal phrases and abbreviations. It is dangerous for a physician to develop their own "language," as others may not understand the phrases and abbreviations used. For example, Stedman’s AE identify the abbreviation for Diabetes Mellitus as DM, yet some physicians will abbreviate it as D. Many notes contain a compression of ideas and in physician haste, omit the connectives that are generally found in sentences. For example, "Heart is regular at 82 without murmurs, clicks, or rubs."

The volume and validity of information obtained through history taking is limited by the patient’s memory, intelligence, and ability and willingness to communicate this information to the physician. There are times when the same question will be asked of the patient three times and on the third time the answer is different. It is important to document if the patient is a poor historian, the patient is unconscious, the patient intubated, or if the patient has a dementia or a mental deficiency. By documenting these roadblocks to obtaining an accurate history, the individual reading the medical record will understand that the history was not skipped, but was unobtainable. Terms and phrases that can be used for this documentation are: declines, refuses, only limited history available, unobtainable, hard of hearing, unreliable, non-committal, confused, evasive, etc.

The documentation components of the history portion of the visit consist of the chief complaint, history of present illness, review of systems, and past, family, social history. To document a solid history it is important to clearly understand why the patient sought care. This information is many times in the patient’s own words and is generally a short statement. It should be brief, specific and symptom-oriented. For example, "Here for blood pressure check," or " Patient here for sore throat." Vague documentation of the reason for the visit or chief complaint should be avoided, as most times it does not state why the patient sought care. For example some documentation reads "Check up," "Routine visit" or "Follow-up." None of these examples state why the patient sought care. A recent note in a patient medical record is as follows:

This documentation of a patient encounter does not identify why the patient sought care, feeling better from what, continue what meds, and lastly, return for a check on what.

Use phrases such as "According to the husband," "According to old records," and "History obtained by nursing home documents" are helpful when documenting the patient’s history portion of the encounter.

The history of present illness (HPI) is a story behind the patient’s reason for the visit. There are two levels of HPI: brief and extended. A brief HPI consists of the documentation of one to three of the following elements. An extended HPI consists of the documentation of four or more elements, or the status of at least three chronic conditions. The eight HPI elements are: location, quality, duration, severity, timing, context, modifying factors, and associated signs and symptoms.

Location: This element is documented by citing a body part or by documenting certain phrases, such as deep in the joint, ill-defined, or unilateral, to mention a few.

Quality: This element is documented by describing the paid or sensation, such as, numb, sharp, itching, gnawing, throbbing, pinching, heaviness, sore, pins and needles.

Duration: This element is documented by noting when the condition or pain started, such as, it started early this morning, I noticed it after dinner, or I have had this pain for the last two weeks.

Severity: This element is documented by using a pain scale of 1-10, or by using terms such as, severe, mild, crushing, faint, unbearable, or doubled with pain.

Timing: These elements are documented by terms such as constant, intermittent, occasional, unrelenting, coming in waves, etc.

Context: This element is documented by a description of what the patient was doing at the time this began. For example, Mr. Patient was watching television when this occurred, or Mrs. Patient was jogging when this started.

Modifying Factors: This is the documentation of either aggravating or alleviating factors or maybe both. Examples of an aggravating factor would be: it gets worse when standing, it is precipitated by coughing, or it is brought on by eating tomato sauce. Examples of alleviating factors would be: it gets better when laying down, after burping, or it is better after being on the medicine.

Associated signs and symptoms: This element is documented by identification of what else happened when this occurred. For example, the chest pain was accompanied by pain down my left arm, since the reflux, there is a lot of burping, or there is pain in leg along with the low back pain.

The past, family, social history (PFSH) can be documented as pertinent, which is the documentation of one history area; or complete, which is dependent on the category of E&M service. Such services as initial hospital services (H&P), require the documentation of all three history areas. Past medical history consists of documentation of the patient’s medications, past surgeries and hospitalizations, past illnesses or injuries.

Allergies and immunizations may also be documented in the PFSH. Family history consists of the age and health, or cause of death of immediate (parents, siblings and children) family members. Social history consists of personal information about the patient’s life, which is non-medical in nature. For example, documentation of military service, occupation, employment, living arrangements, marital status, and whether or not the patient smokes, drinks alcoholic beverages or uses recreational drugs.

Part Two of this article will be published in November of 2008.

Alice Anne Andress, CCS-P, CCP is the Director of Physician Services at Parente Randolph, LLC.