Wiki HELP! HPI Question

[cm@rlin]

I am having difficulty on the HPI elements of this note. The more I look at it the more I second guess myself. Any help on the HPI elements would be greatly appreciated!!
Here is the HPI:
The patient presents for a sleep evaluation. The referring provider is XXXX. ( The patient is here to review a recent diagnostic polysomnogram.) The sleep problem has been occurring in a persistent pattern. Daytime symptoms include daytime sleepiness, decreased energy, fatigue and hypertension. The patient reports snoring and snoring every night. The patient reports mouth breathing during sleep but denies awakening with shortness of breath or awakening with choking feeling. and goes to bet at 12am. On days off the patient wakes up at 6am and goes to bed at 10pm. Usually falls asleep within 3 hours. patient feels that 8 hours of sleep is needed per night. Patient awakes 1 time at night and is awake for The patient wakes up for use of bathroom. During the first few minutes after awakening the patient feels very groggy after waking up.

I know I can get Timing and Associated signs/symptoms. Could you use the fact that the patient is here to review a recent diagnostic polysomnogram as Context? Could the fact that the patient feels that 8 hours of sleep is needed per night be used as a Modifying Factor?? Would this be considered Quality, "During the first few minutes after awakening the patient feels very groggy after waking up"??

 

[david.wagner]

I am having difficulty on the HPI elements of this note. The more I look at it the more I second guess myself. Any help on the HPI elements would be greatly appreciated!!
Here is the HPI:
The patient presents for a sleep evaluation. The referring provider is XXXX. ( The patient is here to review a recent diagnostic polysomnogram.) The sleep problem has been occurring in a persistent pattern. Daytime symptoms include daytime sleepiness, decreased energy, fatigue and hypertension. The patient reports snoring and snoring every night. The patient reports mouth breathing during sleep but denies awakening with shortness of breath or awakening with choking feeling. and goes to bet at 12am. On days off the patient wakes up at 6am and goes to bed at 10pm. Usually falls asleep within 3 hours. patient feels that 8 hours of sleep is needed per night. Patient awakes 1 time at night and is awake for The patient wakes up for use of bathroom. During the first few minutes after awakening the patient feels very groggy after waking up.

I know I can get Timing and Associated signs/symptoms. Could you use the fact that the patient is here to review a recent diagnostic polysomnogram as Context? Could the fact that the patient feels that 8 hours of sleep is needed per night be used as a Modifying Factor?? Would this be considered Quality, "During the first few minutes after awakening the patient feels very groggy after waking up"??

I would not use the diagnostic polysomnogram as context. Context refers to what activity did the patient do that contributed to the problem. I also wouldn't use the 8 hours of sleep for modifying factor. Modifying factor has to state what was done to improve the problem and if it did or didn't help. So, an example for this would be the patient states they roll over to their stomach and sleep that way to help stop snoring, or something to that affect. The "feels very groggy" would be alright for quality. In this HPI I only count 3 elements.

 

[cm@rlin]

I would not use the diagnostic polysomnogram as context. Context refers to what activity did the patient do that contributed to the problem. I also wouldn't use the 8 hours of sleep for modifying factor. Modifying factor has to state what was done to improve the problem and if it did or didn't help. So, an example for this would be the patient states they roll over to their stomach and sleep that way to help stop snoring, or something to that affect. The "feels very groggy" would be alright for quality. In this HPI I only count 3 elements.

Thank you. Your responses as for the context and modifying factors are what I originally thought, but the more I researched HPI elements from other sites, the more I was seeing something that just isn't there.

I have been tasked with doing a focused audit on a provider for new level visits and the HPI documentation is similar for the type of example I demonstrated.

I also see where the provider documents that the condition, we will say "sleep problem", does not effect the patient's work, driving or relationships. Would you count this as a modifying factor? I don't think it is a modifying factor because a modifying factor is something that effects the condition, not how the condition affects something. Thoughts??

 

[david.wagner]

I also see where the provider documents that the condition, we will say "sleep problem", does not effect the patient's work, driving or relationships. Would you count this as a modifying factor? I don't think it is a modifying factor because a modifying factor is something that effects the condition, not how the condition affects something. Thoughts??

That wouldn't be a modifying factor either. Modifying factor is strictly, what did the patient do to try to alleviate the problem or symptoms (ie, raised legs, took Tylenol, slept on side or stomach, put ice on it), and how did that affect it (helped with pain, no effect, made symptoms worse, felt better in the morning). The important thing about modifying factor is that it answers those two questions, What did the patient do to help? What did it do?

 

[Kris Cummings]

I know we all have our own ideas of what the elements stand for in HPI. Here's my two cents.

The patient presents for a sleep evaluation. The referring provider is XXXX. ( The patient is here to review a recent diagnostic polysomnogram.) The sleep problem has been occurring in a persistent pattern(Context; it's a sleeping problem and occurrs in a consistent pattern (it's why they're being seen and treated). Daytime symptoms include daytime sleepiness (Timing), decreased energy, fatigue and hypertension (assoc sx's). The patient reports snoring and snoring every night (Quality). The patient reports mouth breathing during sleep but denies awakening with shortness of breath or awakening with choking feeling. and goes to bet at 12(Quality, negative assoc sx's and timing). On days off the patient wakes up at 6am and goes to bed at 10am (timing). Usually falls asleep within 3 hours (Context; it takes them about three hours just to get to sleep). patient feels that 8 hours of sleep is needed per night. Patient awakes 1 time at night and is awake for (is he/she missing documentation here?) The patient wakes up for use of bathroom. During the first few minutes after awakening the patient feels very groggy after waking up (Assoc Sx's).

This is a great document that discusses HPI elements: http://www.hcca-info.org/Portals/0/PDFs/Resources/library/Audit Manual.pdf

Hope that helps!