Components of a Note

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Components of Note (E/M Guidelines)

Components of a Note -

To Start With:

Chief Complaint: A concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient’s words.

Counseling: A discussion with a patient and/or family concerning one or more of the following areas: diagnostic results; impressions and/or recommended diagnostic studies; prognosis; risks and benefits of treatment options; instructions for treatment and/or follow up; importance of compliance; risk factor reduction; patient and family education of custom essay.

Evaluation and Management Services Consists of 3 Key Components:

– History – Examination – Medical Decision Making (MDM)

Other Factors:

Counseling, coordination of care, nature of presenting problem and time.

New Patient: Must have 3 out of 3 components

Established Patient: Must have 2 out of 3 components

History Section of the Note:

• History of Present Illness (HPI)

• Past, Family & Social History (PFSH)

• Review of Systems (ROS)

HPI Components:

• Context – worsening, chronic, recurrent

• Quality – sharp or dull pain

• Severity – mild, moderate or extreme

• Timing – during exercise, at night, etc.

• Modifying factors – heat/cold, rest, limb elevation

• Duration – for the last ___ yrs, getting worse over the last ___ months

HPI Criteria: Brief 1-3 Elements Extended > 3 Elements

Past, Family and/or Social History Section

• The PFSH consists of a review of these areas:

– Past History (the patient’s past experiences with illnesses, operations, injuries and treatments)

– Family History (a review of medical events in the patient’s family, including diseases which may be hereditary or which place the patient at risk)

– Social History (an age appropriate review of past and current activities) Two levels of PFSH

• Pertinent: at least one specific item from any of the three history areas must be documented

• Complete: at least one specific item from each of the three history areas must be documented (New Patient) or at least one specific item from two of the three history areas must be documented (Established Patient)


Review of Systems (ROS)

• A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. This information is considered subjective vs. the objective information obtained through they provider's physical examination.

Those Body Systems Include the Following:

• Constitutional

• Eyes

• ENT

• Cardio

• Respiratory

• Gastro

• Musculoskeletal

• Integumentary

• Neurological

• Psychiatric

• Endocrine

• Hema/Lymph

• Allergy/Immunology

Three Levels of ROS

Problem Pertinent 1 System

Extended 2-9 Systems

Complete 10 Systems

Guidelines for ROS:

• The patient’s positive responses and pertinent negatives for the system related to the problem should be documented.

• For a complete ROS, those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, a least 10 systems must be individually documented.


Physical Examination

Four levels of service:

1. Problem Focused = 1-5 elements in one or more organ system(s) or body area(s)

2. Expanded Problem Focused = 6-11 elements

3. Detailed = 12 or more elements

4. Comprehensive = Complete single organ system exam or multi-general system exam

Recognized Organ Systems: • Constitutional (3 vital signs, general appearance) • Eyes • ENT • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/Lymphatic/Immunologic

Final Documentation/Coding Component:

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.

• The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

• The number of possible diagnoses and/or the number of management options that must be considered.

And finally, when does time become a factor?

In the case where counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face to face time in the office or other outpatient setting), time is considered the key or controlling factor to qualify for a particular level of E/M service.

What is a SOAP Note?