Chief Complaint: Description of the reason for the encounter (i.e. follow-up evaluation of obesity) History of Present Illness (HPI): Details describing the chief complaint

Quality: Characteristics of the problem - Acute / chronic, sharp / thin, deterioration / improvement, color Est Pt 99211 99212 99213 99214 99215

Severity: The severity of the problem - 1-10, compared with the stage (ie morbid obesity). . Not applicable 1-3 1-3 1-3 4 4

Time: occurrence and progress of problem - time occurred, repeated, continued 1-3 1-3 4 4 4

Background: what the patient is doing when there is a problem - during sleep, after exercise, stress, when getting off the stairs

Correction factor: what the patient did to solve the problem - taking aspirin, using ice, improving after rest, two exercises

Relevant symptoms / symptoms: other symptoms associated with the problem, systemic symptoms, exercise-induced asthma

1 system = problem relation 2-9 system = extension 10 + system = newly created Pt 99201 99202 99203 99204 99205

Symptoms: weight loss / increase, fatigue, fever / chills, sweating, headache, appetite Est Pt 99211 99212 99213 99214 99215

Allergy / Immunology: Pharmaceutical / Food / Pet Allergy, Hay Flour, HIV / AIDS, Immune Condition Not applicable 2-9

Internal: Consult with color change, itching, rash, itching, urticaria, warts, hair loss, chest pain / excretion / lump 99241 99242 99243 99244 99245

Eye: Change in visual acuity, haze, dryness, pain, cataract, glasses / contact, photophobia 1 2 - 9 10 10

Tinnitus, tinnitus, discharge, pain, obstruction, sinusitis, PND, nosebleeds, sore throat, difficulty swallowing, ulcer pain

Cardiovascular system: chest pain during exercise, tweeting, angina pectoris, HTN, MI, palpitation, thrombosis, PVD, DVT,

Musculoskeletal system: pain, weakness, cramping, joint pain, swelling, arthritis, strain / strain / fracture, scoliosis, atrophy

Gastrointestinal tract: fullness, nausea, vomiting, heartburn, diarrhea, constipation, abdominal pain, hematemesis

Nervous system: syncope, seizure, dizziness, adjustment, memory loss, paralysis, tremor, power failure, ataxia, numbness

Urogenital system: dysuria, hematuria, frequency, burning sensation, urgency, kidney stone, sexually transmitted diseases, infertility, menstruation

Mental illness: depression, anxiety, hallucination, suicidal ideation, nervousness, emotional change, substance abuse, poisoning, new Pt 99201 99202 99203 99204 99205

Past history: No previous illness, hospitalization, surgery, injury, current medication is applicable

Family history: Similar disease in family, health status / relatives consultation reasons for death 99241 99242 99243 99244 99245

Social history: Personal identity, customs, employment, sexual history, alcohol / tobacco use 1 3 3

Limited dx / tx option, limited data volume / complexity, low risk = low complexity (low) new Pt 99201 99202 99203 99204 99205

Multiple dx / tx options, multiple quantities / complex data, medium risk = moderate complexity (mod) sf sf low mod high

Extensive dx / tx option, massive data / complex data, high risk = high complexity (high) Est Pt 99211 99212 99213 99214 99215

Reproduction of ICAAP license to improve quality of childhood obesity prevention and treatment care program

The clinician will explore the main problem of the patient as much as possible and discuss the clues obtained during the complaint. The medical history (HPI) of the disease includes the patient's recent and distant medical history related to understanding the current disease. Upon completion of the HPI, the physician will usually be asked about the patient's past medical history (eg, history of hypertension in a stroke patient), the family history of the patient (eg, family history of breast cancer in the patient), and social history Household incongruity in patients with fatigue)

Evaluating low authority problems starts with the history of ordinary complaints. Beginnings, periods and features of complaints are important. A method and a method for not reviewing a good history record. As with other problems, when approaching a patient with foot problems, it is important to compare the possibilities when recording history. The two most important clues on foot and leg lesions are: Place of complaint and kind of illness. This position determines the structure to be affected and its potential decreases from understanding the structures affected