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.
DG: The medical record should clearly reflect the chief complaint
HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:
– location,
– quality,
– severity,
– duration,
– timing,
– context,
– modifying factors, and
– associated signs and symptoms.
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).
A brief HPI consists of one to three elements of the HPI.
The medical record should describe one to three elements of the
present illness (HPI).
An extended HPI consists of four or more elements of the HPI.
The medical record should describe four or more elements of the
present illness (HPI) or associated comorbidities
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).
A brief HPI consists of one to three elements of the HPI.
The medical record should describe one to three elements of the
present illness (HPI).
An extended HPI consists of four or more elements of the HPI.
: The medical record should describe four or more elements of the
present illness (HPI) or associated comorbidities
