Signs and symptoms....

[cpicerno]

Hi... I have an issue with the History of Present Illness (HPI) of one of our patients, I have to get 4 areas out of the HPI and it states "ran into trailer/cut on left leg". Would you consider "cut" as an associated sign and symptom??

[kellyross]

No. All you have is "location" here... with what you've provided. An associated sign or symptom would be more like - maybe "swelling" or something like that. Hope that helps. If it is stated when the incident happened, you would also have "duration".

[ollielooya]

hello, from the note supplied there are not enough elements to reach the 4 you seek. I see location as kelly listed and "cut" would be the CC. You have information to assign E codes, but definitely lack 4 elements for the HPI. All you have here is a brief HPI. ---Suzanne E. Byrum CPC

[rthames052006]

Originally Posted by cpicerno

Hi... I have an issue with the History of Present Illness (HPI) of one of our patients, I have to get 4 areas out of the HPI and it states "ran into trailer/cut on left leg". Would you consider "cut" as an associated sign and symptom??

"Ran into trailer" would be your context from what I see listed above. I am not sure what you mean by " I have to get 4 areas of the HPI'' you don't "have to". It's more like "you'd like to" but if the documentation is not there, it's just not there. This would be an opportunity for you to provide some education/training to the provider in this case.

May I ask what is the patients chief complaint here, I see what's listed above but is the patient complaining of leg pain, bruising, swelling etc.... we really don't know from the above few words that are provided. Is this exactly how the provider has this documented? If so, scary to say the least.

[ollielooya]

Roxanne, thanks for your explanation. I do see where I missed the context COMPLETELY! Appreciate you jumping in with your insight and experience. ---Suzanne E. Byrum CPC