In determining an Evaluation and Management code, which part of the chart provides the detailed history and examination?

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In evaluating E/M services, the level of code is determined by the amount of history gathered and the extent of the physical examination documented, along with the medical decision making. The part of the chart that contains the patient’s detailed history and the clinician’s findings from the actual examination is the History and Physical. This section includes the history of present illness, review of systems, and past, family, and social history, plus the physical examination findings that describe what was examined and observed. Other sections serve different purposes: diagnostic tests provide test results, the operative report documents procedures performed, and the admission note covers inpatient admission details, not the routine history and exam used to determine the E/M level.