Documenting History: Squaring Clinician And Auditor Perspectives
When evaluating medical record documentation to identify specific elements of history including the history of present illness (HPI) and the review of systems (ROS), auditors frequently rely on an audit tool or form to “check off” specific elements as they are identified in the record. They are then able to use this information as part of an education and feedback session to assist providers to understand potential deficiencies in medical record documentation in comparison to a reported Evaluation & Management (E/M) code.
At times, however, providers respond as though the auditor is using criteria outside the scope of what a healthcare practitioner should be capturing in their documentation. The reality is that auditors measure elements of HPI and ROS according to the same clinical documentation specifications that medical students are taught early in their journey to become clinicians. The Bates’ Guide to Physical Examination and History Taking, authored by Barbara Bates and first released in 1974, has been published in several revised editions and has become a standard text for healthcare practitioners and medical students. The Bates Guide clearly identifies the exact same components of chief complaint, HPI and ROS that auditors look for in assessing the extent of a documented medical history.
Comprehensive documentation of the elements of history understandably becomes more concise as clinicians become proficient and familiar with the clinical method. However, it’s important to note, concise should not be misconstrued as incomplete and the documentation of relevant elements of chief complaint (CC), HPI and ROS should be consistent with the patient’s needs, the provider’s goals for the assessment, the clinical setting (office or hospital) and the amount of time available. The extent of the HPI and ROS documented is entirely dependent upon clinical judgment and the nature of the presenting problem. Corresponding E/M codes reflect the amount of work performed and documented in obtaining the history including the history of present illness and review of systems. Auditors use the stated requirements for history including the HPI and ROS for each level of the E/M service to determine the appropriate level of code supported by the clinical documentation.
Breaking down the pieces
The chief complaint is the first thing we’ll cover. Clinicians are taught the chief complaint or reason for visit must be captured in the patient’s own words. While this is generally the most optimal format, there will be situations when a patient is uncertain or vague about their reason for visit. An example of this is a patient who presents stating that they are “here for test results”. The provider must recognize this does not support a valid reason for services but instead should document the medical condition that prompted the test or tests to be performed.
The History of Present Illness (HPI) is next. This should be a complete, clear, and chronologic account of the problems prompting the patient to seek medical care. According to Bates, the HPI should contain factors including the problems onset, the setting in which it has developed, its manifestations, and any treatment. There are several broad questions which are applicable to any complaint. Medical students may be taught a mnemonic for the eight dimensions of a medical problem which can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity). These attributes of every symptom are the same elements auditors use in assessing the extent of the documentation of HPI. In fact, auditors have the option to include one further aspect, the status of three (or more) chronic illnesses or conditions. This additional aspect of HPI can be helpful in identifying a HPI for well-established patients seen at regular intervals and who are without specific acute complaints identified in the above dimensions.
There are two levels of HPI:
Brief HPI: Requires one to three HPI elements.
Extended HPI: Requires four HPI elements or the status of three chronic problems.
The Review of Systems (ROS) is the third and final piece we’ll examine here. For clinicians, the review of systems or symptoms is a list of questions, generally arranged by organ system, designed to identify clinical symptoms the patient may have overlooked or forgotten. Ideally, the review of systems is designed to elicit information which the patient may not consider important enough to mention to the physician but that may identify additional conditions to be evaluated. The extent of information obtained through the review of systems may impact the extent of the physical exam performed and the corresponding assessment and plan of care. There are no specific rules regarding how much information must be asked about each system; this is generally left to the discretion of the clinician. The CPT manual as well as the CMS E/M Documentation Guidelines specifically identifies 14 individual body systems the clinician may inquire about.
Furthermore, there are three recognized levels of review of systems as recognized by the coding guidelines utilized by auditors.
Problem Pertinent ROS: Review of one system related to current problem(s)
Extended ROS: Review of two to nine systems
Complete ROS: Review of at least 10 systems
Healthcare providers should understand professional medical auditors have not created new or unfamiliar criteria by which they evaluate the content and extent of documentation to assess conformance with a level of service. The specific details of documentation for HPI and ROS are based on the same structured framework for organizing patient information they were taught as students.