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Evaluation and Management Scoring Card

 
 

For New Patients

Three (3) elements at that level are required

For Established Patients

Two (2) elements out of three are required

History Documentation

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, and/or Social History (PFSH)

Type of History

Brief

1 - 3 elements

N/A

N/A

Problem Focused

Brief

1 - 3 elements

Problem Pertinent

1 system

N/A

Expanded Problem Focused

Extended

4 - 7 elements

Extended

2- 9 systems

Pertinent

1 area

Detailed

Extended

4 - 7 elements

Complete

10 systems

Complete

2 - 3 areas

Comprehensive

Examination Documentation

Perform and Document

Level of Exam

1 -5 elements identified by a bullet

Problem Focused

At least six elements identified by a bullet

Expanded Problem Focused

At least twelve elements identified by a bullet.

Detailed

Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

Comprehensive

 
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