Which documentation type includes Chief Complaint, extended HPI, pertinent system review, and extended to include a review of a limited number of additional system, pertinent past, family, and social history? (2 - 9 systems)

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

Answer: (D)

The question is about the level of documentation used in history and systems review. A Detailed documentation level includes a Chief Complaint and an extended History of Present Illness, plus a review of systems that is extended to cover a limited number of additional systems (typically 2–9), along with a Past, Family, and Social History that is pertinent to the problem. This combination indicates more depth than a focused visit but stops short of a complete, multi-system ROS and full PFSH. Therefore, the described documentation aligns with a Detailed level.

Expanded problem-focused would have a more limited ROS and less extensive HPI, and comprehensive would require a complete ROS (10+ systems) and a complete PFSH. The 2–9 systems and pertinent history described point to Detailed as the best fit.