Can you count the chief complaint as an HPI element?

cornutts

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Hello, my boss and I are in disagreement about this. I do not believe you can use the CC as an HPI element as she is telling me I can.
Who is right? If I am right, do you know where I can find documentation to support this?

Thank you!
 

thomas7331

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I don't think you will find an answer to this in any official guidelines. None of the guidelines I'm familiar with say that you cannot use the information in the chief complaint as part of the HPI, and in my opinion, there would be nothing wrong with doing this. It is not 'double dipping' because you aren't count any 'points' in a chief complaint in order to meet a certain level. There no reason I can see that the information in the CC couldn't be used toward history, and there would be no logical reason to require a provider to record the information twice just in order to count it. CMS guidelines only state that the "the medical record should clearly reflect the chief complaint", so the record is required to contain this information, but it doesn't specify that it needs to be kept separate from the history. That's just my take on it, but hope it helps some.
 

twizzle

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I don't think you will find an answer to this in any official guidelines. None of the guidelines I'm familiar with say that you cannot use the information in the chief complaint as part of the HPI, and in my opinion, there would be nothing wrong with doing this. It is not 'double dipping' because you aren't count any 'points' in a chief complaint in order to meet a certain level. There no reason I can see that the information in the CC couldn't be used toward history, and there would be no logical reason to require a provider to record the information twice just in order to count it. CMS guidelines only state that the "the medical record should clearly reflect the chief complaint", so the record is required to contain this information, but it doesn't specify that it needs to be kept separate from the history. That's just my take on it, but hope it helps some.
Good answer Thomas. I completely agree.
 

ellzeycoding

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I guess it depends on what exactly is written in the CC.

For example...

CC: patient complains of itchy lesion on left arm.

Here you can get two HPIs... Location = left arm and quality = itchy
 
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