bwerner
Networker
My surgeon dictated a consult on a patient that was sent to him because he had a positive hemoccult. He hits the points everywhere in his dictation except in his HPI (I think).
The man isn't presenting with a current illness.
This is his HPI
"He was sent for consultation and consideration of colonoscopy. The patient in general states that he is feeling well. He tends to have one to two bowel movements a day. He denies any bright red blood per rectum or melanotic stools that he has noticed. In addition he denies any diarrhea or constipation. No alteration in his bowel habits. No weight loss. No change in appetite. He denies any FH of colon cancer. He denies any prior colonoscopy or known history of colities. He does have a history of hypercholesterolemia that is being managed medically."
He needs 4 elements or status of 3 chronic problems. I believe that these are more of a ROS than any elements. What do you think, should they be considered elements and if so, which do they fall under.
The man isn't presenting with a current illness.
This is his HPI
"He was sent for consultation and consideration of colonoscopy. The patient in general states that he is feeling well. He tends to have one to two bowel movements a day. He denies any bright red blood per rectum or melanotic stools that he has noticed. In addition he denies any diarrhea or constipation. No alteration in his bowel habits. No weight loss. No change in appetite. He denies any FH of colon cancer. He denies any prior colonoscopy or known history of colities. He does have a history of hypercholesterolemia that is being managed medically."
He needs 4 elements or status of 3 chronic problems. I believe that these are more of a ROS than any elements. What do you think, should they be considered elements and if so, which do they fall under.