Ritecode.com - E and M Scorecard

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