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Definition of Modifying Factors debate

ollielooya

True Blue
Messages
900
Location
Everett, WA
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Need help from colleagues with the following chart note. Debate going on whether the underlined statement does indeed qualify as modifying factor and if not, why?

The patient presents on an urgent care basis during regular office hours. The patient is a 36-year-old African_american female established patient with a fours day history of sinus congestion, sore throat, laryngitis, and cough with yellow to clear sputum production. She has been treating this with over_the_counter antihistamines without relief and states that she feels like she is not getting better] She denies any fevers or chills however: her temperature today is high. She has been on allegra and sudafed in the past for sinus problems but they have not recently been refilled.

Since the antihistamines did not relieve the problem (modify) it would not be counted as a modifying factor being the argument. I disagree with this as the patient did try "modifying" it on their own with their own choice of treatment and that it should be considered as a modifying factor in the HPI.

Do you agree and please submit why you would disagree as I would really like to follow up with some collective support.
 

sullivak

Guru
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125
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It should count. I think a good analogue is how we think of exam elements. Just because someone has "no abdominal tenderness" does not mean a GI exam wasn't done. Quite the opposite.
I would count this as a modifying factor because the physician is documenting what the patient reported did not work. I would also count any kind of statement such as "OTC pain relievers don't relieve the pain".
The overall rationale and goal of requiring HPI components is to encourage physicians to get this information from the patient by asking and listening.
 

Lassal423

Guest
Messages
70
Location
Denver
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It definitely counts as a Modifying Factor. From the CMS guidelines on the definition:

'What treatment/actions have had an effect (positive or negative) on the Chief Complaint?'

Lora
 
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