Abstract
This paper will explain what the role of the patient’s history is in determining the correct evaluation and management code. I will list and explain the four elements of the patients’ history and I will give an example of what might be found in that element.

The history section is the portion of the record that tells the physician what is wrong, and is based on the four elements. The patient is the one to supply the information for the history section. This section is where the provider can determine and assess the condition of the patient, by the history provided. The ancillary staffs personal are allowed to document this section of the medical record for the provider. They are permitted to document the chief complaint that the patient is complaining of. This section also contains any past history such as surgeries, child births if you a women. The family history is recorded here as well. This part of the history gives detail about the illness that other family members may have or have had. Cancer, heart dieses, diabetes just to name a few conditions that may be inherited from family members. There is also the social section of the history. This section speaks about your habits, do you drink and how much, do you spoke cigarettes and how many, are you a drug user and what type of drug are you using. Some physicians have special forms to be filled out that gives all the information that is required without the staff questioning you. If the history information is obtained through this method it is the provider’s responsibility to ensure that all the information is correct. The four elements of the history section are the chief complaint (CC). This section is an accurate statement that describes what the patient is having problems with. It documents the symptoms in the patient’s own words. The next element is the history of present illness or (HPI). This section provides a time line in the order that it happened. If you come in complaining of a sore throat and a cough, it documents from the time you first felt you throat being sore and when you started coughing. How long has this been going on when it started? What makes it worst or better? The next section is the review of the systems or the (ROS). This section probes for symptoms that the patient may have forgotten of found unrelated or unimportant. This section runs through the body systems in detail asking the patient to report any changes to theses symptoms. This section should be verified by the provider. The last section is past, family and social history or (PFSH). This section contains all the information about your past illnesses and your family’s illnesses.
As a coder it is your responsibility to be able to read what the physician has documented in the medical records. And code them properly.

In conclusion I have gone over the four elements of the history section of the records. I have given the information of what each section contains, what order they are given in and who should document the information.

References:
Buck, C. (2007). Step-by-step medical coding. St. Louis, MO: Saunders.