Wiki "As noted" in HPI

[Inquisitor]

When a provider has a mandate for documentation to be submitted to the payer with every bill and the provider's electronic transcript includes a Chief Complaint and a patient statement that is autopopulated from information entered by ancillary staff on another database, does the provider get credited with the Chief Complaint and HPI elements if under HPI he notes, "As noted" and continues with additional HPI?

Example: (Entered by Ancillary staff)
Chief Complaint: 56 yo female employee of XXXX (company) with laceration of thigh ocurring at 5 pm today.
Patient States: Opening box, boxcutter sliced right hand.
HPI: (entered by provider)
As above, washed/wrapped wound before presenting to clinic. Large wound. Pt is left handed. Denies numbness, tingling, weakness.

Would one count the Chief Complaint noted above and any HPI gleaned from CC and patient statement since the provider seems to be confirming the information, or does the provider actually have to re-state all the information above?

 

[LLovett]

My understanding is the provider is the only one that can obtain the HPI, so referring to the CC obtained by ancillary staff does not get any credit for HPI elements.




Laura, CPC

 

[FTessaBartels]

I'd give credit

I'd give credit because the provider is adding additional HPI information him/herself. I wouldn't make them retype everything.

In your example I count the word "wound" as CC; plus 3 elements of HPI by the provider:
Modifying factors (washed/wrapped)
Severity (large)
Assoc Sign/Symptom (no numbness, tingling)

Interestingly enough the person who entered CC states "laceration of thigh" and later "sliced right hand" -- so I wonder just where the wound is?

If the doctor had clarified that s/he'd have a 4th element (location).

F Tessa Bartels CPC, CEMC

 

[Inquisitor]

You'd give credit, but only counting the details listed within the HPI itself? (
By the way, this was not a specific case, just a typo as far as thigh or hand. Let's assume CC and Pt statement were both hand.) Just because he states, "As above" does not allow you to glean duration and location from the Chief Complaint or patient statement, correct?