History of Present Illness

This section should provide a description of what initially brought the patient into the ED, what the main concerns were, and why family or law enforcement brought the patient into the ED.

Include the most recent information on the exacerbation of their mental health symptoms that lead to this current ED visit. The time period or interval that should be addressed, typically, is the past several weeks prior to the ED arrival. Depending on the presenting complaint, this may go back to last time the patient was admitted to an inpatient psychiatric hospital. The purpose of this time frame is to paint an adequate picture upon which future clinical decisions can be built.

If the patient is currently prescribed medications, this section should include the patient’s history of adherence to their regimen. If the patient is not adherent to the medication regimen, list the reasons why this has occurred, and if there are any reported side effects from the medications.

A review of the presenting symptoms should also be included in this section. The following specifiers should be documented:

  • ? Perceived severity of the symptoms
  • ? The self-reported duration, which can be hours, days, or weeks
  • ? Frequency of experiencing the symptoms
  • ? How these symptoms affect their ability to function
  • ? Their ability to hold and maintain employment
  • ? Their ability to form and maintain relationships with others, including family and friends

While billing and coding is certainly a valid reason to obtain as many specifiers as possible, the clinical reason to elicit this information is to allow the patient to tell their story and express how much their problems are bothering them.

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