Another HPI question

maine4me

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In a patient with multiple chronic conditions if the doctor actually lists the status in his plan, can I pull this information for HPI? Someone once told me to disregard the category headings and pull the information from anywhere on the note. Just wondering what others would do.
 
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You may use status of chronic conditions OR HPI...depends on how the note was documented. If you have identification of chronic conditions with a status also documented ie; stable, controlled, unstable, worsening, improved etc this will take the place of HPI.

You don't have to worry about interchanging them. I would however look at both status of chroninc conditions if documented appropriately and HPI. If Dr did a good job with HPI then use HPI elements. If he did great with documenting status of chronic conditions then score it that way.
 

rthames052006

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In a patient with multiple chronic conditions if the doctor actually lists the status in his plan, can I pull this information for HPI? Someone once told me to disregard the category headings and pull the information from anywhere on the note. Just wondering what others would do.
Is your provider managing, taking care of or addressing these chronic issues that are being mentioned.
 
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