Which documentation level includes Chief Complaint, extended HPI, pertinent system review, plus all additional systems (at least 10), complete past, family, and social history?

• A. Comprehensive
• B. Detailed
• C. Expanded Problem Focused
• D. Problem Focused

Answer: (A)

When evaluating the level of documentation, the history portion must show a broad and complete gathering of patient information. A comprehensive history includes an extended HPI with substantial detail, a complete review of systems that covers all body systems (often described as 10 or more), and complete Past Medical, Family, and Social History. The described documentation fits this: it starts with the Chief Complaint, then provides an extended HPI with ample detail, includes a ROS that covers the pertinent system plus all additional systems (meeting the requirement of at least 10 systems), and finishes with a full Past, Family, and Social History. These elements together indicate the highest level of historical documentation, which is why this choice is correct.