¶ … Management Services: The determination of the suitable level of services provided during a patient's visit normally requires the identification of whether the patient is new or already established to the hospital. This is followed by the clinician's use of the presenting illness and clinical judgment as leading factors that help in identifying the extent of care services to be carried out based on the condition of the patient. In addition to this, there are key components and contributing factors that are used in the determination of the level of evaluation and management services provided to the specific patient.

Key Components and the Contributing Factors:

While a clinician can use the presenting illness and clinical judgment in evaluation and management of patients' services, there are key components and contributing factors that can also be utilized. Actually the documentation of evaluation and management services is usually based on these components ("Introduction and Definitions," n.d.). These vital elements of service and documentation that are used in counseling and coordination of patient care include:

History:

History is one of the most important parts of determining the level of evaluation and management services offered to a new or already established patient. The history is developed to act as a narrative that provides information regarding the medical problems and symptoms being tackled during the encounter. According to the guidelines of evaluation and management of services, there...

Despite of these differences in the levels of history, they all require a chief complaint or certain form of interval history or History of Present Illness (HPI). Problem Focused and Expanded Problem Focused histories require brief HPI whereas the Detailed and Comprehensive ones require extended HPI. The review of systems is not applicable in Problem Focused history though the Expanded Problem Focused requires problem and pertinent review of systems. In contrast, Detailed and Comprehensive histories require extended and complete review of systems respectively. As Detailed and Comprehensive also need pertinent and complete past, family, and/or social history respectively, the concept is not applicable in the other types or levels of history.
Notably, the extent of information collected for history is based on the nature of the existing problem and clinical judgment. However, the documentation of patient history can include some or all of these elements i.e. The patient's chief complaint, History of Present Illness, Review of Systems, and past, family, and/or social history ("Evaluation and Management Services Guide," 2010).

Physical Examination:

As the other integral part of evaluation and management of services offered to a patient, physical examination may incorporate various organ systems or a single one. The extent of…