Which of the following elements is typically included in an evaluation and management encounter?

In an evaluation and management (E/M) encounter, the chief complaint is a fundamental element. It refers to the primary reason the patient presents for medical attention and is typically documented at the beginning of the patient encounter in the medical record. The chief complaint helps guide the healthcare provider's assessment and decision-making during the examination and subsequent treatment planning. It is essential for establishing the context of the visit and is a key component in determining the complexity and level of service provided during the encounter.

While the diagnosis, billing details, and referral history may be relevant to a patient's overall care and encounter documentation, the chief complaint is specifically required for E/M coding and serves as an indicator of the patient's main concern during the visit, thus providing a clear starting point for the clinical assessment and care process.