Physician-Patient Encounters – The Physician Perspective


Physician-Patient Encounters – The Physician Perspective


Michael Stearns, MD, CPC

HIT Consultant

High Level Physician Goals

  • Develop a rapport with the patient
  • Establish credibility with the patient
  • Establish the reliability of the patient
  • Gather information
  • From the history
  • From the examination
  • From test results
  • From reports from other providers
  • Get through the examination efficiently
  • Get paid, if surgical get cases…
  • Don’t get sued
  • Don’t become subjected to a negative audit
  • Have the patient say good things about you in the community, in particular to the physician who referred the patient to you.

Develop a rapport with the patient

  • Polite and professional
  • Not too reserved
  • Not too friendly
  • Appear knowledgeable
  • Patient may know more about a disease than you do after, for example, performing on-line research
  • Keep the patient on task, but interrupt them as little as possible
  • Can be very challenging…

Establish Credibility with the Patient

  • Be a good listener
  • EHRs can interfere with this process
  • Demonstrate familiarity with their complaints and ask insightful questions
  • Communication in a way they can easily understand, without coming across as patronizing

Establish the Reliability of the Patient

  • Need, in some cases to identify how to interpret information you are provided
  • Secondary gain such as what may be seen in a disability payment
  • Psychological issues
  • Embellishment tied to :
    • Fears that underlying condition is serious in nature
    • Fears that they will not be taken seriously unless they “amplify” the severity of their symptoms

Prioritize Nature of Visit

  • Use the history, physical and the results of diagnostic studies to form an impression of what might be influencing the patient’s health
  • Identify potential emergent conditions
    • Sometimes seconds matter
  • Focus on conditions that can be treated first
  • Be very wary of making assumptions that could lead to misdiagnosis

Chief Complaint

  • Typically a brief statement that starts the note
  • Includes:
  • Background demographics
  • Some background medical information
  • Reason they are being seen, often in the patient’s own words
  • For example:
  • The patient is a 44-year-old white male with a history of hypertension and diabetes who presents with “numbness in my toes.”
  • There are wide number of variation as to how this is structured
  • Documentation guidelines (for reimbursement) state that a CC must be present, but it can be part of the HPI.

History of Present Illness

  • Basically the story behind the visit
  • 80% of the diagnosis comes from the HPI
  • Iterative process
  • Series of questions and answers
  • Follows logical course
  • Requires expert knowledge of how diseases present
  • Physician may develop a short list of diagnoses (in their mind) that he/she is considering
    • Responses to questions drive next question
    • Somewhat algorithmic
    • Eliminate some conditions
    • Confirm others
    • Gives weighting to certain conditions  over others in many cases
  • Somewhat algorithmic
  • Eliminate some conditions
  • Confirm others
  • >Gives weighting to certain conditions  over others in many cases
  • May include relevant past medical information
  • Relevant medications
  • Responses to prior treatments
  • Underlying diseases
  • Prior injuries or events (e.g., trauma)
  • Family history
  • Social history
  • Summary of relevant recent events
  • Recent hospitalizations
  • Recent surgeries
  • Prior evaluations by other providers
  • Stressors that could influence health
    • E.g., Work-related stress
  • HPI documentation goals
  • Document information for purely clinical use
    • Reference notes for point of care use
    • Future visits
    • Information to be used for care at other locations
  • Reference notes for point of care use
  • Future visits
  • Information to be used for care at other locations
    • Medicolegal documentation
    • Demonstrate that the standard of care was met via documentation
  • Medicolegal documentation
    • Demonstrate that the standard of care was met via documentation
    • Be wary of template defaults and cloning of information
  • Demonstrate that the standard of care was met via documentation
  • Be wary of template defaults and cloning of information
  • Reimbursement purposes
    • HPI heavily influences coding and reimbursement
    • Need 1-4 HPI elements OR 3 chronic diseases and their statuses
    • Used to determine E&M level of service

The HPI and EHRs

  • Enter complex information and overcome natural language challenges
  • Free text via voice recognition, typing or other methods one approach
    • Loses structured data
    • May be offset by NLP and automated coding
  • Loses structured data
  • May be offset by NLP and automated coding
  • Templates/Macros popular in EHRs
    • Need to capture as many potential questions as possible through drop down lists with branches
    • Huge amount of potential information could be needed
    • HPI templates generally are difficult to build
    • Well constructed templates have the ability to remind physicians of certain questions that should be asked
  • Templates must take into consideration:
  • Clinical knowledge to aid with documentation
  • Medicolegal considerations
    • Were all the relevant questions asked and documented in case the care of the patient was to later be challenged
  • Coding and billing questions
    • Needs to code for the HPI elements (duration, location, severity, quality, modifying factors, context, associated signs and symptoms and timing)
    • Alternative is to have capacity to recognize when three chronic conditions and their statuses are documented
  • Template models vary widely between EHR systems
  • Usually context specific
  • E.g., New patient headache, follow-up diabetes, etc.
  • Usually specialty specific
  • Very different level of detail may be needed depending on specialty

Past Medical, Family and Social History

  • Often the next section of the history and physical (H&P) after HPI
  • May be entered by the patient, taken by the MA, or in some cases imported electronically
  • Typically reviewed by the provider before they see the patient
  • Provider will use information from the section to help with determining the diagnosis

Past Medical History

  • Often obtained prior to the patient being seen by the provider and reviewed by the provider before seeing the patient
  • Complete history, regardless of relevancy
  • Can be labor intensive for patient/staff to record
  • Past medical history usually contains:
  • Medications
  • Allergies
  • Current and former illnesses and injuries
  • Surgeries
  • Hospitalizations
  • Immunization History
  • Birth History
  • Others

Problem List

  • Was a separate sheet in the front of paper chart, used in inpatient records and in some specialties
  • Has evolved with advent of EHRs to be central component of patient record
  • Generally a subset of information from the past medical history, limited to relevant conditions that are currently active
  • Use varies markedly
  • Central focus of interoperability efforts via CCD

Past Family History

  • Can be limited to a screening history of relevant medical conditions in the patient’s family history
  • Weighted towards conditions that have known tendency to be passed from one generation to another
  • E.g., Huntington’s Disease
  • Can have less relevance in elderly patients
  • Will take on a great deal of new significance in the genomic medicine era

Social History

  • Usually includes:
  • Occupation
  • Marital History
  • Living Situation
    • Family members when relevant
  • Alcohol Use
  • Drug Use
  • Sexual History
  • Other Social Factors

Provider Considerations for PFSH

  • Make sure all relevant information is obtained
  • Make sure items that could adversely impact patient care are captured
  • Medicolegal considerations (e.g., missed drug allergy)
  • Important for decision support applications, like e-prescribing CDS tools
  • Needs to be placed into correct sections of EHR to be used for E&M coding
  • All three needed for highest coding levels
  • Avoid defaults that bring in too much information and falsely elevate coding levels

HIT Considerations for the PFSH

  • As compared to the HPI, this section is much more easily “codified”
  • More applicable to interoperability
  • Medications, problems (usually selected items from the past medical history), allergies and labs are now shared via CCD
  • EHRs and other HIT systems have limited capabilities to import and export this data, but this is rapidly evolving

HIT Considerations for the PSFH

  • Importing data directly from an HIE or other source needs to be done carefully
  • Data can be corrupted
  • E.g., wrong code used and then interpreted incorrectly by receiving system
  • Incomplete or inaccurate data can impact patient care
    • Negation can corrupt data
    • Uncertainty can corrupt data
  • Data integrity is a rapidly emerging area of HIT
  • EHR
  • May provide templates
  • May require specialty specific templates
    • E.g., details of prior surgeries for surgical subspecialty like orthopedics
    • E.g., details of prior surgeries for surgical subspecialty like orthopedics
  • Data may be codified at point of capture
    • ICD-9-CM in most cases
    • CPT in some instances
    • SNOMED CT emerging
  • ICD-9-CM in most cases
  • May need to interact with an immunization module, and state registries


Review of Systems

  • Inventory of current body systems
  • Basically a screen following the HPI and PFSH to identify any other symptoms or patient identified findings that were not previously addressed in HPI
  • Typically about 14 systems are used
  • E.g., respiratory system, cardiovascular system, etc.
  • Labor intensive
  • Can lead to discovery of new information that could markedly impact diagnosis and care decisions
  • Can also be a time intensive pursuit of information that is not relevant for that specific encounter
  • Questions like “are you experiencing fatigue” are potentially going to yield a high percentage of positive responses that the provider may feel obligated to pursue….
  • What is the provider thinking?
  • Don’t miss anything relevant that could impact the care of the patient
    • Patient care concerns
    • Medicolegal concerns
      • EHRs allow for default normals or cloning in ROS; common to see conflicts with HPI
    • Get the information needed to justify the level of service (e.g., E&M code)
  • Obtain and document the information as efficiently as possible, i.e., avoid having this take away from time spend in other areas of the encounter
  • EHR considerations
  • This can be a major workflow consideration
    • Patients can enter the data
      • Via kiosk, patient portal, personal health record, forms that can be scanned, etc.
      • May need to translate medical information to something patients can consume
    • MA or other ancillary staff can enter data provided by patients in writing, or taken directly from the patient
    • Provider may take the ROS, but in general they review information entered by others
  • Tendency for fraud relatively high in this section due to lack of interaction with HPI
    • Common for finding in HPI to be in conflict with ROS
    • Suggests fraud given that ROS defaults are common settings in EHRs

Physical Examination

  • Typically includes
  • Measured vital signs: height, weight, blood pressure, pulse, respirations
  • Direct observations
  • Findings on inspections
  • Some test results may be included (e.g., smear of fluids obtained during procedure)
  • Very specialty specific
  • Often very much targeted based on patient’s presenting complaints
  • “Full” physical could take 2 hours to complete
  • Very data intensive for abnormal findings
  • May have varying names
  • Eponyms used frequently
  • What is the provider thinking?
  • Don’t miss something that could make a difference in the patient’s care
  • Perform an adequate examination of the relevant organ system, and document it, to demonstrate the standard of care was met
  • Document findings in organs system that were medically relevant to examine and captured for level of service determination

EHR Considerations for PE

  • Massive amounts of content needed
  • LArge templates
  • Coding rules very complicated in E&M guidelines
  • 1995 Guidelines nebulous
  • 1997 Guidelines very specific and specialty appropriate – Used by most EHRs
  • Ideal for computational assistance
  • Frequently cited reason why providers purchase an EHR, i.e., to code visits more accurately
  • Defaults for normal examinations are faster than dictating, however normal defaults have to be used cautiously..
  • E.g., normal lower extremities documented in a patient who has a leg amputation
  • The government is watching….
  • Pulling forward a prior examination can be very efficient, but needs to be done with caution
  • Providers need to review each character on the screen and take ownership

 Labs, test results and procedures

  • Often placed between physical and assessment
  • May be in other locations
  • Includes:
    • Lab values obtained prior to or during the visit
    • Radiology findings obtained prior to or during the visit
    • Reports from other providers
    • Procedures performed as part of the encounter
      • E.g., draining fluid from a knee

Provider Considerations

  • What is the provider thinking?
  • Quickly assemble all relevant information to help with making the diagnosis and treatment plan
  • Don’t miss something relevant that would be considered part of the standard of care
  • Capture the fact that the information was reviewed for reimbursement (E&M) purposes
  • Enter the information efficiently

EHR Considerations

  • EHR may or may not have ability to import information of this nature into H&P note
  • Often will not have ability to capture this as information relevant to E&M coding
  • Point system is used when providers look at test results, look at actual images, etc.
  • Need to be documented but can influence level of complexity of visit
  • May not have ability to template the procedure, which are the most straightforward types of encounters to document in EHRs


  • Provider pulls together all relevant information and often creates a “differential diagnosis”
  • Differential diagnosis is a weighted list of potential diagnoses
  • Ranked based on
    • Potential urgency
    • Can the problem be treated
    • What is the most likely underlying disease
    • What else needs to be considered?
      • “Zebras”

Provider Considerations

  • What is the provider thinking?
  • Demonstrate that all relevant diagnoses, based on clinical relevance, have been considered
  • Demonstrate thought process behind conclusions
  • Demonstrate level of knowledge to other providers (in particular for specialists)
  • Demonstrate that the patient has been made fully informed regarding their condition

EHR Considerations

  • Create tools that assist with diagnosis
  • CDS
  • List of alternative diagnoses to consider
  • Access to knowledge resources
  • Import diagnoses from other sections of the record
  • Modify diagnoses
  • Choose codes needed for billing of the encounter
  • Justify complexity of visit through description of patient’s problem and potential risks to their future health, and the risk of interventions


  • Includes
  • Diagnostic tests
    • Treatments
    • Medications
    • Surgeries
    • Therapy
    • Others
  • Patient instructions
  • Follow-up care
    • Return visits
    • Referrals to other providers
  • What is the provider thinking?
  • Prescribe medications where risk is offset by potential benefit
    • Fully inform patient of potential risks
  • Order tests that confirm diagnosis or eliminate diagnoses under consideration
  • Refer patients as appropriate to other care provider such as specialists
  • Follow a plan of care that would be consistent with the standard of care
    • Patient education and counseling of particular importance
  • Capture information that will be used for level of service (E&M)

EHR Considerations

  • Interact with data entered in other sections of record to assist provider with management
  • CDS (e.g., medication contraindications)
  • Standards of care for specific conditions
    • E.g., correct antibiotic to use
  • Capture what was discussed with the patient
  • Macros, templates, free text or VR often used
  • Present provider with coding summary, including level of service (E&M) coding assistance tools
  • Allow provider to close note and send relevant information to a billing tool.

Author contact information


Michael Stearns, MD

HIT Consultant

Email address:

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