Medical necessity is demonstrated based on information captured in the history of present illness (HPI). Documentation quality matters more than quantity. The information should be relevant to the presenting problem(s), and it should seek to answer the questions each HPI element asks, as follows:

Location: e.g., Back pain, Nasal Congestion

Quality: e.g., sharp or shooting pain, dry cough

Severity: e.g., extremely nauseated, moderate pain

Duration: e.g., Onset two weeks ago

Timing: e.g., Worse in the mornings, Occurs constantly

Context: e.g., Dizzy upon standing, Worse after excersice

Associated Signs/Symptoms: e.g., a chief complaint of nausea may be accompanied by associated symptoms of vomiting and diarrhea

Modifying Factors: e.g. No relief from OTC meds, Improves with rest

Note that only the performing provider may document HPI. Copying the nurse’s notes or patient responses in a questionaire does not count.