Patient History Form Chief Complaint History of Present 2025

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Key Elements of an HPI Form Onset: When did the symptoms start? Location: Where are the symptoms located? Duration: How long have the symptoms been present? Character: What is the nature of the symptoms (e.g., sharp, dull, throbbing)? Aggravating factors: What makes the symptoms worse?
Chief Complaint (CC): The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.
The Chief Complaint (CC) and History of Present Illness (HPI) typically include the reason for the medical visit, a chronological account of symptoms associated with the patients experience of illness, and, when pertinent to the reason for seeking care, elements of the past medical history, demographics, and social
The chief complaint (CC) is recorded in the history of present illness (HPI) and review of systems (ROS). Where does the scribe document the patients previous diagnoses or surgeries? Previous diagnoses or surgeries are recorded in the patients past medical history.
Documentation of each patient encounter should include: Reason for encounter and relevant history. Appropriate history and physical exam in relationship to the patients chief complaint. Review of lab, x-ray data and other ancillary services, where appropriate.
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All levels of history require a chief complaint and some form of HPI (or Interval History), but not all levels of history require an ROS or PFSH. The following table shows the individual requirements for each level of history. The Problem Focused History is the lowest and least descriptive level of history.
The CC should be a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patients own words.

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