Medical Records Management

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Reason for the encounter and relevant history (Subjective)

  1. History of Present Illness

  2. Review of Systems

  3. Past, Family, and/or Social History.

  1. EXAM

  1. Physical findings and prior or current diagnostic test results (Objective)

  2. General Multisystem Exam,

  3. Diagnostic Procedures Ordered.


  1. Assessment and identification of health risk factors, clinical impression, or diagnosis, i.e., Presenting Problems Management Options Categories. (Assessment)

  2. Plan for care, i.e., recommendations, prescriptions for medications, diet or exercise modification, health education and counseling, and a plan of return to clinic. i.e., Management Options. (Plan)

Date and legible identity of provider.


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 symptoms or from the previous encounter to the present.

  1. LOCATION: Are s/s are diffused or localized, unilateral or bilateral, fixed or migratory? i.e. breast tenderness, rt. ankle swollen, discharge from left ear.

  2. QUALITY: Specific pattern of complaint, or character/quality of the s/s. Ex. sharp, dull, throbbing, constant or intermittent, acute or chronic, stable, improving or worsening, malodorous, cloudy or clear, i.e. sharp abdominal pain, foul vaginal discharge.

  3. SEVERITY: Presence, absence and/or severity of any condition/discomfort, sensation or pain? Or does the history indicate the absence of any condition/discomfort, s/s. i.e. no c/o’s today, denies pain with exercise, c/o headache, n/v.

  4. DURATION: Does the history indicate the duration of the s/s or problems? i.e. BTB x 3 mo., pain in left shoulder for 2 weeks.

  5. TIMING: Does the history indicate the onset or cessation of the s/s or problems? i.e. LMP, EDC, pain started yesterday

  6. CONTEXT: Does the history describe the patient’s locale or activity when the s/s began? When is the problem aggravated or relieved? i.e. pain with exercise, burning upon urination.

  7. MODIFYING FACTORS: Does the history indicate what the patient has done to obtain relief? Has the patient used OTC drugs or attempted to see a MD and did it improve the condition? Exposure to STD/HIV, toxins TB, etc.? i.e. seen per MD for URI, Tylenol for headache.

  8. ASSOCIATED S/S: Does the history list any associated s/s? such as n/v, headache, sweating, vaginal bleeding, rash, etc.?

  9. CHRONIC/INACTIVE CONDITIONS: Does the history indicate the status of at least 3 chronic/inactive conditions? i.e. hypertension, diabetes, migraine headaches, arthritis, asthma, etc. These can be found primarily on the CH-13, CH-14.


  1. 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.

  2. CONSTITUTIONAL SYMPTOMS: i.e., fever, weight change, appetite, fatigue. i.e. history of weight loss or gain, decreased or increased appetite, unexplained tiredness.

  3. EYES: sclera, conjunctiva, pupils, etc.

  4. CARDIOVASCULAR: lungs, heart, vascular, abdomen. i.e. SOB

  5. RESPIRATORY: nose, mouth, lungs, heart, peripheral vascular, or skin (nails). i.e. history of asthma, TB contact.

  6. GASTROINTESTIONAL: eyes – in relation to icterus, mouth & pharynx, lymphatic, abdomen, rectal, skin – in relation to jaundice, liver, gallbladder.

  7. GENITOURINARY: breasts, abdomen, back, external genitalia, vagina, cervix, uterus, adnexa, ovaries, penis, scrotum, testicles/epididymis, prostate, spermatic cord.

  8. MUSCULOSKELETAL: joints, muscles, bones, range of motion

  9. INTEGUMENTARY: (skin and/or breast), lymphatic, peripheral vascular, sensory nerves

  10. NEUROLOGICAL: higher cortial function, cranial nerves, motor nerves, coordination, gait and station

  11. PSYCHIATRIC: orientation, mood and affect, thought flow, thought content, attention, concentration, knowledge, abstract reasoning, judgment, insight, pathological reflexes

  12. ENDOCRINE: thyroid, goiter, tumors




  1. Past History: The patient’s experience with illness, operations, injuries, and treatment.

    • Current medications

    • Prior major illness and injury

    • Prior operations

    • Prior hospitalizations

    • Allergies

    • Genetic abnormalities

    • Age appropriate immunization status

  2. Family History: A review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk.

  • Health status

  • Genetic abnormalities

  • Cause of death of parents, siblings, children, father of baby

  • Specific diseases related to problems identified in the chief complaint, history of present illness, and/or review of systems

  1. Social History: An age appropriate review of past and current activities

  • Marital status and/or living conditions

  • Employment

  • Occupational history

  • Use of drugs, alcohol and tobacco

  • Dietary habits

  • Extent of education

  • Sexual history


  1. CONSTITUTIONAL: i.e. WN/WD (well nourished, well developed)

    1. Measurement of any 3 of the following 7 vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be recorded by ancillary staff)

    2. General appearance of patient = i.e., development, nutrition, body habitus, deformities, attention to grooming.

  1. EYES:

    1. Inspection of conjunctiva and lids

    2. Examination of pupils and irises (i.e. reaction to light and accommodation, size and symmetry)

    3. Ophthalmoscopic examination of optic discs (i.e. size, C/D ratio, and appearance) and posterior segments (i.e., vessel changes, exudates, hemorrhages)


    1. External inspection of ears and nose (i.e., overall appearance, scars, lesions, masses)

    2. Otoscopic examination of external auditory canals and tympanic membranes

    3. Assessment of hearing (i.e., whispered voice, finger rub, tuning fork)

    4. Inspection nasal mucosa, septum and turbinates

    5. Inspection of lips, teeth, and gums

    6. Examination of oropharynx, oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

  1. NECK:

    1. Examination of neck (i.e., masses, overall appearance, symmetry, tracheal position, crepitus)

    2. Examination of thyroid (i.e., enlargement, tenderness, mass)


    1. Assessment of respiratory effort (i.e., intercostal retractions, use of accessory muscles, diaphragmatic movement)

    2. Percussion of chest (i.e., dullness, flatness, hyperresonance)

    3. Palpation of chest (i.e., tactile fremitus)

    4. Auscultation of lungs (i.e., breath sounds, adventitious sounds, rubs)

    5. Palpation of heart (i.e., location, size, thrills)


  1. Auscultation of heart with notation for abnormal sounds and murmurs

  2. Examination of:

      • Carotid arteries (pulse, amplitude, bruits)

      • Abdominal aorta (size, bruits)

      • Femoral arteries (pulse, amplitude, bruits)

      • Pedal pulses (pulse, amplitude)

      • Extremities for edema and/or varicosities

  1. CHEST:

    1. (BREASTS) Inspection of breasts (symmetry, nipple discharge)

    2. Palpation of breasts and axillae (masses or lumps, tenderness)


    1. Examination of abdomen with notation of presence of masses or tenderness

    2. Examination of liver and spleen

    3. Examination for presence or absence of hernia

    4. Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses

    5. Obtain a stool sample for occult test when indicated


    1. Male:

      • Exam of scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass)

      • Exam of penis

      • Digital rectal exam of prostate gland (size, symmetry, nodularity, tenderness)

    2. Female:

    • Pelvic exam with/without collection for smears and cultures

    • Exam of external genitalia (general appearance, hair distribution, lesions) and vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

    • Exam of urethra (masses, tenderness, scarring)

    • Exam of bladder (fullness, masses, tenderness)

    • Cervix (general appearance, lesions, discharge)

    • Uterus (size, contour, position, mobility, tenderness, consistency, descent or support)

    • Adnexa/parametria (masses, tenderness, organomegaly, nodularity)


    1. Palpation of lymph nodes in 2 or more areas:

    2. Neck

    3. Axillae

    4. Groin

    5. Other


  1. Examination of gait and station

  2. Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechia, ischemia, infections, nodes)

  3. Examination of joints, bones, muscles of 1 or more of the following 6 areas: 1) head and neck, 2) spine, ribs, and pelvis, 3) right upper extremity, 4) left upper extremity, 5) right lower extremity, 6) left lower extremity

  4. The examination of a given area includes:

      • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions

      • Assessment of range of motion with notation of any pain, crepitation or contracture

      • Assessment of stability with notation of any dislocation (luxation), subluxation, or laxity

      • Assessment of muscle strength and tone (flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

  1. SKIN: i.e. Skin w/d, no rashes or lesions

    1. Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers)

    2. Palpation of skin and subcutaneous tissue (induration, subcutaneous nodules, tightening)


    1. Test cranial nerves with notation of any deficits

    2. Examination of deep tendon reflexes with notation of pathological reflexes (Babinski)

    3. Examination of sensation (touch, pin, vibration)

  1. PSYCHIATRIC: i.e. A & O x 4 (alert and oriented)

    1. Description of patient’s judgment and insight

    2. Brief assessment of mental status, including:

    3. Orientation of time, place, person, and date

    4. Recent or remote memory

    5. Mood and affect (depression, anxiety, agitation)



  1. Number of self limited or minor problems; i.e., cold, insect bite, tinea corporis, headache, lice, dermatitis; no apparent contraindications to immunizations/contraceptive methods.

  2. Acute uncomplicated illness or injury, i.e., cystitis, URI, allergic rhinitis, pharyngitis, simple sprain, STD’s, OM.

  3. Number of chronic illnesses with mild exacerbation, progression, or side effects of treatment, i.e., uncontrolled diabetes or hypertension.

  4. Undiagnosed new problem with uncertain prognosis, i.e., lump in breast, abnormal pap smear, chest pain, developmental delay; true contraindication to immunization/contraceptive methods.

  5. Acute condition or illness with systemic symptoms, i.e., pregnancy, pyelonephritis, pneumonitis, colitis, TB.

  6. Acute complicated injuries, i.e., head injury with loss of consciousness

  7. Number of chronic illnesses with severe exacerbation, progression, or side effects of treatment.

  8. Acute or chronic condition, illness or injury that may pose a threat to life or bodily function, i.e., AIDS, high-risk pregnancy.

  9. Abrupt change in neurological status, i.e., seizure, TIA, weakness or sensory loss.

DIAGNOSTIC PROCEDURES ORDERED - Labs performed or ordered

  1. Laboratory tests, venipuncture/capillary; skin tests\

  2. X-rays, chest/extremities; EKG/EEG; mammography; axial tomography

  3. Cultures, i.e., strep Urinalysis, i.e., urine dip, pregnancy tests

  4. Ultrasound, i.e., echocardiography

  5. Cystologic/microscopic tests, i.e., Pap smears, wet preps, hemocults

  6. Developmental tests, i.e., Denver, DASE Physiologic tests not under stress, i.e., pulmonary function, fetal non-stress, malabsorption allergy

  7. Non-cardiovascular imaging studies with contrast or air injection, i.e., barium enema

  8. Superficial needle biopsies. Skin biopsies.

  9. Blood gases Physiologic tests under stress, i.e., cardiac stress test, fetal contraction test

  10. Diagnostic endoscopies with no identified risks, i.e., colposcopy

  11. Deep needle, incisional biopsy, excisional biopsy, i.e., conization, LEEP

  12. Cardiovascular imaging studies with contrast and no identified risks, i.e., arteriogram, cardiac cath.

  13. Obtain fluid from body cavity, i.e., lumbar puncture, thoracentesis, culdocentesis, aminocentesis, colposcopy

  14. Cardiovascular imaging studies with contrast with identified risk factors

  15. Cardiovascular electrophysiological tests

  16. Diagnostic endoscopies with identified risks, i.e., arthroscopy, thoracoscopy, laproscopy

  17. Discography, MRI

MANAGEMENT OPTIONS SELECTED - Performed, Referred or Ordered

  1. Rest, limit activity, guidance for follow-up care. i.e., RTC (appt. date)

  2. Gargles, ointments, creams

  3. Minor procedures – nonsurgical i.e., irrigation of wound or ear

  4. Superficial dressings, bandaids, gauze, elastic bandages, i.e., ACE

  5. Over-the-counter drugs, management/instructions. Ex Condoms

  6. Minor surgery with no identified risk factors

  7. Physical therapy; occupational therapy; skilled nursing (HH)

  8. Counseling, i.e., general diet, behavioral risk, health education

  9. IV fluids without additives

  10. Minor surgery with identified risk factors; emergency room treatment; referral to specialist, i.e., OB/GYN, Pediatrician, etc.

  11. Hospital admission with/without elective major surgery (no identified risk factors)

  12. Medical nutritional counseling, referral to RD

  13. Therapeutive nuclear medicine, i.e., radiation treatments

  14. IV fluids with additives, prescriptive drug management, therapeutic injection, i.e., Rocephin, immunizations

  15. Closed treatment of fracture or dislocation without manipulation

  16. Subsequent E/M visits for intensive monitoring of high risk pregnancy

  17. Elective major surgery (with identified risk factors)

  18. Emergency major surgery

  19. Parenteral controlled substances, i.e., chemotherapy

  20. Drug therapy requiring intensive monitoring for toxicity

The Core Clinical Service Guide and the Administrative Reference (Volumes I and II) contain the current specific data collection and documentation requirements that comply with state and federal laws, regulations and guidelines.

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