'Click to return to E/M University Home page, EM Coding Education
Problem Focused History



Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.


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. 


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.

Home   |   Contact Us   |   Privacy Policy
Copyright © 2003 -  EM University. Web Design: Abacus Web Services
Click to return to E/M University Home page, EM Coding Education