Wiki CC used in HPI points

[PeaPod1]

Can the CC be counted when scoring HPI points?

Ex.
CC: Abdominal Pain
HPI: Patient presents with abdominal pain for the last week. etc. etc. etc.

I would normally use the abdominal pain for location and quality. I have a co-worker that has interpreted something that she has read to say that you cannot count it because it was stated in the CC. I have never heard of anything like this??

Any input is greatly appreciated. I am worried she is really underscoring her providers HPI because of this.

I posed this question to the presenter for this week's webinar and she did not understand and just answered back about who can document CC... not what I was asking

 

[MnTwins29]

Not if documented in note

I believe your co-worker is incorrect as abdominal pain is documented in the note itself and not just as the CC. Like you, I would use abdomen as location in your example.

 

[FTessaBartels]

As long as it is restated

I agree with Lance ... as long as the information is restated in the HPI I would use it.

Hope that helps.

F Tessa Bartels, CPC, CEMC