This document outlines important terms and criteria for different types of medical documentation forms. It discusses the key elements that should be included in documentation, such as the chief complaint, history of present illness, review of systems, and past/family history. It also describes different levels of complexity in patient cases and the types of decision making and documentation required. The goal of medical documentation is to comprehensively yet efficiently record all relevant health information about a patient.

1. MEDICAL RECORD
DOCUMENTATION
OR
CASE SHEET PREPARATION
By
Vinod Pagidipalli

2. IMPORTANT TERMS TO MEMORIZE
A New patient is defined as one who has not received any professional services from the
physician or another physician of the same specialty who belongs to the same group within
the past 3 years.
An Established patient is one who has received professional services from the physician or
another physician of the same specialty who belongs to the same group within the past 3
years.
Note - There is no distinction made between new and established patients in the emergency department.

3. CLASSIFICATION OF DOCUMENTATION
FORMS
There are 4 Types of Case Sheet Documentation forms. Based on the Inclusive and
Exclusive
Analysis and Assessment - such as Diagnosis, Severity, Duration, Dependency,
Complication etc.
1. Problem Focussed
2. Expanded Problem Focused
3. Detailed
4. Comprehensive

4. CRITERIA FOR DOCUMENTATION
FORMS
Type Of Documentation Form Criteria required
Problem Focussed New patient, Minimal Symptoms, unorganised etc
E.g. Fever, Cold etc
Expanded Problem Focussed New or Established, Bacterial, Viral or Fungal Infected, Moderate Symptoms, may or may not be organised
or complicated.
E.g. Dengue, Sinusitis etc
Detailed Acute Symptoms, Organised, Complicated, Fatal
E.g. Kidney Failure, Shock, Poisoning etc
Comprehensive Chronic/Acute Symptoms, Organised, Highly Complicated, Fatal, Non Curable, Irreversible Injury.
E.g. Hypertension, Diabetes, Neoplasms

5. CRITERIA IMPLICATIONS
Type of Doc.
form
Chief
Complaint
History of
Present Illness
Review of
Systems
Past, Family
and/or Social
history
Problem Focussed Required Brief NE NE
Expanded Problem Required Brief Problem Pertinent NE
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
NE – Not Essential

6. ELEMENTS REQUIRED FOR
DOCUMENTATION
The Documentation of Patient Health Information form/ Medical Record/Patient Case Sheet
includes some or all following elements.
A. CHIEF COMPLAINT (CC)
B. HISTORY OF PRESENT ILLNESS (HPI)
C. REVIEW OF SYSTEMS (ROS)
D. PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)
E. COMPLEXITY
F. DECISION MAKING
G. DOCUMENTATION

7. A. CHIEF COMPLAINT (CC)
The chief complaint is a concise statement that describes the symptom, problem,
condition, diagnosis, or reason for the patient encounter.
It is usually stated in the patient’s own words OR patient’s care taker words.
For e.g., “I am anxious, feel depressed, and am tired all the time.”
OR
“He was being anxious, depressed and tired all the time.”

8. B. HISTORY OF PRESENT ILLNESS
(HPI)
• Location (e.g., feeling depressed)
• Quality (e.g., hopeless, helpless, worried)
• Severity (e.g., 8 on a scale of 1 to 10)
• Duration (e.g., it started 2 weeks ago)
• Timing (e.g., worse in the morning)
• Context (e.g., fired from job)
• Modifying factors (e.g., feels better with people around)
• Associated signs and symptoms (e.g., loss of appetite, loss of weight,
loss of sexual interest)
The history of present illness 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.
HPI elements are:

9. TYPES OF HPI’S
Brief HPI
Brief includes documentation of one to
three HPI elements. In the following
example, three HPI elements—location,
severity, and duration—are documented:
• CC: Patient complains of depression.
• Brief HPI: Patient complains of feeling
severely depressed for the past 2 weeks.
Extended HPI
Extended includes documentation of at least
four HPI elements or the status of at least
three chronic or inactive conditions.
In the following example, five HPI
elements—location, severity, duration,
context, and modifying factors— are
documented:
• CC: Patient complains of depression.
• Extended HPI: Patient complains of
feelings of depression for the past 2 weeks.
Lost his job 3 weeks ago. Is worried about
finances. Trouble sleeping, loss of appetite,
and loss of sexual interest. Rates depressive
feelings as 8/10.

10. C. REVIEW OF SYSTEMS (ROS)
• Constitutional (e.g., temperature, weight, height, blood pressure)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic
The review of systems is an inventory of body systems obtained by asking a series of
questions in order to identify signs and/or symptoms that the patient may be
experiencing or has experienced. The following systems are recognized:

11. LEVELS OF ROS
1. Problem pertinent, which inquires about the
system directly related to the problem
identified in the HPI. In the following example,
one system—psychiatric— is reviewed:
• CC: Depression.
• ROS: Positive for appetite loss and weight loss of 5 pounds
(gastrointestinal/constitutional).
2. Extended, which inquires about the system
directly related to the problem(s)identified in
the HPI and a limited number (two to nine) of
additional systems. In the following example,
two systems—constitutional and
neurological—are reviewed:
• CC: Depression.
• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early
morning wakefulness.
3. Complete, which inquires about the
system(s) directly related to the problem(s)
identified in the HPI plus all additional
(minimum of 10) body systems. In the
following example, 10 signs and symptoms
are reviewed:
• CC: Patient complains of depression.
• ROS:
a. Constitutional: Weight loss of 5 lb over 3 weeks
b. Eyes: No complaints
c. Ear, nose, mouth, throat: No complaints
d. Cardiovascular: No complaints
e. Respiratory: No complaints
f. Gastrointestinal: Appetite loss
g. Urinary: No complaints
h. Skin: No complaints
i. Neurological: Trouble falling asleep, early morning awakening

12. D. PAST, FAMILY, AND/OR SOCIAL HISTORY
(PFSH)
There are three basic history areas required for a complete PFSH:
1. Past medical/Psychiatric history: Illnesses, operations, injuries, treatments
2. Family history: Family medical history, events, hereditary illnesses
3. Social history: Age-appropriate review of past and current activities
The two levels of PFSH are:
1. Pertinent, which is a review of the history areas directly related to the problem(s) identified
in the HPI. The pertinent PFSH must document one item from any of the three history areas.
In the following example, the patient’s past psychiatric history is reviewed as it relates to the
current HPI:
• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac.
Episode lasted 3 months.
2. Complete. At least one specific item from two of the three basic history areas must be
documented for a complete.

13. E. COMPLEXITY
Each case reported should undergo 4 major questionnaire's in self to draw out the Level of
Complexity of patient.
Q -1 : Can guess the patient condition and provisional report ?
Q- 2 : Are you sure is Diagnostic Investigations are Mandatory/ to be frequent Monitored ?
Q- 3 : Are you sure of reaching therapeutic goal without complications ?
Q- 4 : What if - you Misdiagnose/ Patient not responding / Misinterpreted treatment protocol.
Levels of Complexity – Based on above Questionnaire's
1. Minor - Any 3 or 4 Q – Answerable
2. Feasible/Controllable – Any 2 Q – Answerable
3. Major – Any 1 Q – Answerable
4. Fatal – None or 1 can be Answerable – for not sure

14. F. DECISION MAKING
Based on the Level of complexity and patient condition the decision making varies –
1. General Care – for usual symptoms and reversible related conditions e.g. Diarrhoea , Fever, Maternal care.
2. Isolated Care – for Epidemic diseases and Flu Viral infections e.g. Swine Flu, Nipah, Corona
3. Controlled Care – from Nosocomial & Bacterial Infections and Non Reversible Conditions e.g. Asthma, BP, DM,
4. Prevention Care – for Immunological Diseases, Skin Diseases, Home pest infections e.g. AIDS
5. Psychiatric Care – for Anxiety, Bipolar, Post Trauma Psychiatric disorders & Suicidal Behaviours
6. Emergency Care – for Medico Legal cases, Trauma Accidents, Multiple Fractured injuries e.g. Snake Bite, RTA
7. Critical Care – for Acute disorders and complication related chronic diseases e.g. Cardiac Failure, Diabetic Shock.
8. Intensive Care – for Intensive durational observation for a period of time – Post Surgery care, Neonatal care,

15. E. DOCUMENTATION
Documentation plays a crucial role as it concludes and gives the end part after diagnosis.
It Includes –
1. Non Pharmacological - Nutrition Supplementation, Life Style Modifications such as yoga etc.
2. Pharmacological – Prescription and Treatment Protocol.
3. Patient Counselling – Disease Condition, Complications, Risk Factors, Side effects of Medicines.
If present any Surgical Notes, Past Medication History, Follow up Sheet etc.
**** Mandatory Note - Entire Documentation should be with Quantity and Quality

16. Thank You…!