When To Use Both '95 and '97 Documentation Guidelines
Weigh the Elements
HPI elements are:
- Location (example: left leg)
- Quality (example: aching, burning, radiating pain);
- Severity (example: 10 on a scale of 1 to 10)
- Duration (example: started 3 days ago)
- Timing (example: constant or comes and goes)
- Context (example: lifted large object at work)
- Modifying factors (example: better when heat is applied)
- Associated signs and symptoms (example: numbness in toes)
The two types of HPIs are brief and extended. Whereas a brief HPI includes documentation of one to three HPI elements, an extended HPI:
- 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities.
- 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions.
Centers for Medicare & Medicaid Services, FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services