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The Problem Focused History is the lowest and least descriptive level of history.
This history requires only a chief complaint and a Brief HPI (which requires one to three HPI elements).
No ROS or PFSH are required.
Example
Level 1 hospital progress note (99231) for a patient with nephrolithiasis
CC: Follow-up nephrolithiasis
Interval History: The patient’s left flank pain has resolved.
It may be hard to believe, but that is all that is required for a Problem Focused History for a level 1 hospital progress note.
Notice that a chief complaint is clearly stated and only one HPI element (location) is utilized. |
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