This column recently reviewed the importance of accurately documenting the Complaint or “The Why” of the patient visit (August 2010, available online at PracticalDermatology.com). This has been an area of ongoing confusion for practices, where there is a tendency to inappropriately note what the provider did (such as “check left leg”), rather than appropriately indicate the medical necessity (such as, “f/u rash, left leg”) for the service. Another area of confusion for many practices is documentation of the Review of Systems (ROS), which is the source of many questions submitted to us online via our support service DermAnswers (DermResources.com).

Overall, there seems to be confusion between elements of History of Present Illness (HPI), Past Medical History (PMH), and Review of Systems (ROS), each of which is described below.

History of Present Illness: Specific to a particular complaint, it includes location, duration, modifying factors, quality, timing, context, severity, and signs and symptoms.

Past Medical History: This is comprised of the patient's past experiences with illnesses, operations, injuries and treatments.

Review of Systems: This inventory of body systems is obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced in association with the current complaint.

Generally, the Past Medical History will be comprised of known diagnoses, while the Review of Systems will consists of signs and symptoms related to the complaint that will support the provider in arriving at a diagnosis. The key difference between Past Medical History and Review of Systems is that the ROS identifies signs and symptoms, not known diagnoses.

The HPI and the ROS may overlap. For example, a teaching document by Dr. Richard Rathe of the University of Florida gives the following examples of ROS for the integumentary system: Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes. Many of these could also be documented as signs and symptoms under History of Present Illness.

Importantly, systems other than the integumentary might be reviewed during a dermatology visit, such as asking a patient who presents with urticaria if he/she ever has trouble breathing (respiratory). Other systems will be reviewed but may not have anything to do with the HPI. For example, if you consider prescribing an antibiotic by mouth, you may ask the patient, “Do you get nausea from taking antibiotics by mouth?” (GI) or “Do you get vaginal irritation when taking antibiotics by mouth?” (GU).