The CC is a concise statement that describes the principal reason for the patient’s visit (Gurland, 2015). The physician records the CC in the patient’s own words, and the patient’s medical record should replicate the CC (CMS, 2014). The HPI is developed around the CC and is considered to be a description of the patient’s current ailment beginning with the initial symptoms of illness (CMS, 2014). The five elements that compose the HPI are location, quality, severity, duration, timing, context, alleviating or aggravating factors, and related signs and symptoms (CMS, 2014). Brief and extended are classified as the two types of HPIs. A brief HPI incorporates one to three elements of the HPI, while an extended HPI includes at least four components of the illness or an updated status of three chronic conditions (Miller, 2012). The ROS is collected by asking the patient various questions regarding signs and symptoms experienced in other body systems (Miller, 2012). The ROS is composed of three levels: problem pertinent, extended, and complete (Miller, 2012). The PFSH is also an important part of the history and includes all surgeries, injuries, illnesses, past and current social activities, and a review of family medical events that places the patient at risk in the future (CMS, 2014).…