Table I History (Hx) Component: All three elements in the table must be met and documented. – Requirements Requirements for an Extended HISTORY for a Problem Problem Requirements for Requirements for a ELEMENTS Focused (PF) Focused (EPF) a Detailed (D) Comprehensive (C) Level Extended 4+ Extended 4+ elements elements (requires a (requires a detailed detailed patient patient specific specific description description of the A. History of of the patient's patient's progress Present progress with the with the current TX Brief 1-3 elements Brief 1-3 elements Illness/Injury current TX plan, plan, which should (HPI) should include include objective objective functional functional gains/losses, ADLs) gains/losses, ADLs) B. Review of Problem Systems (ROS) pertinent-limited 2-9 body parts or None Complete 10+ to injured body body systems (not required for part established patient visits) C. Past Medical, Family and Pertinent 1 of 4 2 or more of the 4 None None Social/Work of histories types of histories History (PMFSH) HPI Elements represents the injured worker relaying their condition to the physician and should include the following: Location (where?) Quality (sharp, dull?) Severity (pain level 1-10 or pain diagram) Duration (how long?) Timing (how often, regularity of occurrence, only at night, etc.?) Context (what ADLs or functions aggravates/relieves, accident described?)
Table I – History (Hx) Component: All three elements in the table must be met and documented. HISTORY ELEMENTS Requirements for a Problem Focused (PF) Requirements for an Extended Problem Focused (EPF) Requirements for a Detailed (D) Requirements for a Comprehensive (C) Level A. History of Present Illness/Injury (HPI) Brief 1-3 elements Brief 1-3 elements Extended 4+ elements (requires a detailed patient specific description of the patient's progress with the current TX plan, should include objective functional gains/losses, ADLs) Extended 4+ elements (requires a detailed patient specific description of the patient's progress with the current TX plan, which should include objective functional gains/losses, ADLs) B. Review of Systems (ROS) (not required for established patient visits) None Problem pertinent-limited to injured body part 2-9 body parts or body systems Complete 10+ C. Past Medical, Family and Social/Work History (PMFSH) None None Pertinent 1 of 4 of histories 2 or more of the 4 types of histories HPI Elements represents the injured worker relaying their condition to the physician and should include the following: Location (where?) Quality (sharp, dull?) Severity (pain level 1-10 or pain diagram) Duration (how long?) Timing (how often, regularity of occurrence, only at night, etc.?) Context (what ADLs or functions aggravates/relieves, accident described?)
Rule_18_2018_Exhibit_7_2018.docx