Phrase used to describe a type of medical decision-making when a patient is seen for an evaluation and management service.

Documented report of an inquiry about the body system(s) directly related to the problem(s) identified in the history of present illness (HPI).

1995 documentation guidelines: limited examination of the affected body area or organ system. The health record should describe only one body area or organ system. 1997 documentation guidelines for multisystem examination: performance and documentation of one to five elements identified by a bullet (•) in one or more body or system areas. 1997 documentation guidelines for single organ system examination: performance and documentation of one to five elements identified in a table by a bullet (•), whether in a shaded or unshaded box.

Documentation must include the chief complaint and a brief history of the presenting illness (HPI) or problem.

System of medical recordkeeping that consists of flow sheets, charts, or graphs that allow a physician to quickly locate information and compare evaluations for data such as blood pressure readings, blood sugar levels for diabetic patients, weight for obese patients, medications, and immunizations.

1. ICD-9-CM diagnostic codes that are used when a person who is not currently sick encounters health services for some specific purpose such as to act as a donor of an organ or tissue, receive a vaccination, discuss a problem that is not in itself a disease or injury, seek consultation about family planning, request sterilization, or to obtain supervision of a normal pregnancy. In these situations the V code appears as a primary code and is placed first for the purpose of billing. 2. Codes used to identify a condition that might affect the patient at a future time but is not a current illness or injury. Use a V code to describe an existing situation that might influence potential medical care.

Specific action, process, sequence of steps, or test performed on a patient either to establish a diagnosis or render a therapeutic service (e.g., minor or major surgery, laboratory tests, inserting an intravenous line).