Wiki HPI statement "Patient Feels Fine"

ollielooya

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Does this statement qualify for quality as an element in HPI? I think not, but in reading a descriptor as "what kind", sharp, dull staiing, burning, irritating, throbbing, aching constantly, intermittent---the fact that the patient is devoid of these makes me wonder if "patient feels fine"could be plugged in. Might be a case of my "over-thinking" again. I know this has been addressed on the forum before, but couldn't pull it up.
 
I'm curious what the cheif complaint is...and if the patient feels fine what the purpose of the visit is. If it is a follow up to something, and that was all i had, I would give 1 HPI element of quality.
 
I tend not to count this

First, I work in pediatrics, and more specifically with pediatric surgeons. We only see patients who have some definitive, potentially surgical, problem.

That being said, I usually don't count such nebulous statements for any of the HPI elements.
What would I count as quality? Let's look as specifics rather than generalities ...
Complaint F/U fracture - open vs closed or "greenstick"
complaint DM - type 1 or type 2, controlled or uncontrolled
Complaint hernia - reducible or incarcerated or strangulated
Complaint rash - red, itchy, patchy, scaly

However, I think LindaEV has a valid point. If I could be persuaded to count is as a "negative" report, I might count it as negative for assoc signs/symptoms.
If the patient is coming in for a F/U of DM2, for example, and the only HPI is "patient feels fine" then I think it might count for quality. Still, if you're only going to get ONE HPI element, I'd rather see duration .... e.g. Last seen 2-13-12, and patient feels fine.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
further clarification to one of your posts?

However, I think LindaEV has a valid point. If I could be persuaded to count is as a "negative" report, I might count it as negative for assoc signs/symptoms.
F Tessa Bartels, CPC, CEMC

Please, Tess can you elaborate and/or furnish an example to the "negative report" aspect?
I took the liberty to bold and underline the part in question.
 
Please, Tess can you elaborate and/or furnish an example to the "negative report" aspect?
I took the liberty to bold and underline the part in question.

I would count it as 1 point for severity. See below "coding tool for history" I've attached the link.
Severity; Intensity, degree or measure of a symptom. On a scale of 1-10, how severe is the pain? Ex: mild pain, fever 101, my blood sugar is 175, feels well, no complaints, worse pain I've ever had.

http://www.codingbuzz.com/forms.html
http://www.professionalcodingservices.com/
 
I count negatives

I could negatives ("patient denies" or "no x, y, z") as associated signs/symptoms.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
I could negatives ("patient denies" or "no x, y, z") as associated signs/symptoms.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Hi,

How should be the associated signs and symptoms?
should it be related to cheif complaints related system or anything other than that?
Eg: Pt came with headache and he has palpitation, there is no trauma or injury..

in this case can we consider palpitation as associated sign.

Thanks in advance

Natarajan Chellamuthu, CPC.
 
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