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Problem Focused History
 

 
The Problem Focused History is the lowest and least descriptive level of history.   This history requires only a chief complaint and a Brief HPI (which requires one to three HPI elements).  No ROS or PFSH are required. 


Example

Level 1 hospital progress note (99231) for a patient with nephrolithiasis          

CC: Follow-up nephrolithiasis          


Interval History: The patient’s left flank pain has resolved.

It may be hard to believe, but that is all that is required for a Problem Focused History for a level 1 hospital progress note. 

Notice that a chief complaint is clearly stated and only one HPI element (location) is utilized.
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