Wiki CC/HPI

[Greenpiper]

I have been unable to find information regarding when CC and HPI do not have anything in common. Everything I read states the CC is a medically-necessary reason for the patient to meet with the physician and HPI should explicitly describe the chief complaint. I believe the CC is medically necessary but it has nothing in common with HPI. So what to do with this CC/HPI? Would querying the provider even be appropriate since it has been 4 days since provider signed chart?

CC: DM visit .

History of Present Illness:
had CP worried about angina saw cardilologist negative treatmill lasted several minutes 3-4 attacks

A/P:
DIABETES MELLITUS, TYPE II, CONTROLLED (ICD-250.00) (ICD10-E11.9) doing well no changes
Hyperlipidemia (ICD-272.4) (ICD10-E78.5)
GERD (ICD-530.81) (ICD10-K21.9)
suspect esophageal spasm for chest pain declines firther eval
CAD (ICD-414.00) (ICD10-I25.10) stable

 

[Thilvenkat]

Hi
Complete medical record Consider as CC, HPI, ROS, PFSH, P.E and Assessment & Plan and should finally signed by provider, but above document incomplete to stated above all the Criteria Met. so query to provide complete medical record for Dr office

 

[Pathos]

Per CMS guidelines:
"Chief Complaint (CC)
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC".




While the Chief Complaint should justify the visit, new concerns can pop up during the E/M visit that could lead the visit in a different direction. However, the Chief Complaint should describe the problem and the reason for the encounter. Simply stating "Follow up", or "Med check" is not great documentation. I would recommend providing further education to the provider office, to improve their Chief Complaint statement in order to make this section iron clad against a possible future audit (and documentation integrity in general).

Stating "DM visit" is not great either, however perhaps expanding on that statement to include "DM checkup, doing great so far..." or something along those lines. The HPI could have included some verbiage about DM since the CC is specifically addressing this problem.

Hope this helps!